A comparison of the regulation of health professional boundaries across OECD countries.

• Author: Bourgeault, Ivy Lynn
• Position: Special issue on: "The comparative economics of regulated professions" - Report

1. Introduction (3)

   Increased attention has been paid recently to the issue of the regulation of professional boundaries. Some of this has been a result of the failure of regulation, such as the celebrated cases of Dr. Shipman in the U.K. where a General Practitioner (GP) killed several patients seemingly unnoticed by regulatory bodies (Alsop & Saks 2002) and Dr. Patel in Australia, an overseas trained doctor who undertook tasks beyond his level of competency with grave consequences. But changes to professional regulation in health care seem to be more structural and motivated by deeper social, political and economic considerations. Health care payers (governments, insurers, or employers) are looking for ways to make health care provision more efficient and cost effective and at the same time must be seen as responding to concerns regarding health human resource (HHR) shortages.

   Two interrelated cases of the promotion of inter-professional collaborative care and the reliance on internationally educated health personnel are illustrative in this regard. First, the deployment of inter-professional health care teams has been promoted as a cost-effective response to shortages, even though this means dismantling interprofessional regulatory barriers. Second, intra-professional jurisdictional barriers to mobility are increasingly seen as incompatible with labour mobility, most notably but not exclusively in Europe, and as a cause of the perceived health professionals shortages (4) in some OECD countries (Grignon, Owusu and Sweetman, 2012). If the trend toward the removal of barriers and better integration of health care professionals across professions and borders is clear, how well does it play out within different institutional and cultural contexts? Is the drive toward collaboration and better allocation of resources so strong that it applies similarly across jurisdictions, trumping path dependence, regulatory capture, and institutional gridlock, or do we still see differences across health care systems in the way the regulation of health care professions adjust and change?

   In this paper, we undertake an international comparison of the regulation of health professional boundaries across the OECD countries of Canada, the U.S., the U.K. and Australia--countries that rely heavily on internationally trained health professionals and who have also been leaders in inter-professional collaborative care initiatives. We present findings on two case studies: firstly, inter-professional regulation between physicians (primarily family physicians/general practitioners) and nurses, and, secondly, intra-professional regulation of nationally trained versus internationally trained doctors on the other hand. These two cases illustrate the tension between professional protection afforded through different regulatory regimes on one hand, and perceived inefficiencies, inequities, and political problems (most notably, shortage of health care professionals) generated by that protection. Comparative research recognising the distinct geographic, political and economic contexts of these countries allows us to better understand the role of various institutions in the regulation of the health profession.

   We begin by providing the theoretical lenses for the special treatment of health professions in light of their unique regulatory situation (namely, need to ensure and monitor quality), and how this contradicts other objectives such as efficient allocation of resources, or equality of opportunity and equal access to health care services within countries. We then describe and compare the regulatory context for physicians and nurses in our four case countries. This is followed by a discussion of our two cases across the four country contexts. What is revealed from this analysis is that despite distinct geographic, political and economic contexts, there has been an overall increased permeability of professional boundaries both inter-professionally and intraprofessionally in each of our case countries.

2. The Unique Context Created by Health Professional Self-Regulation

   Health professionals, including physicians and nurses (for whom results are presented in this paper), are licensed professions in most countries and the form this regulation takes is often (but not always) self regulation. As such, they are selected through specific training, the length and content of which is controlled by the profession itself either directly through a college or indirectly through the government, but not by the market. They are granted a position once they complete training. Overall, there is a deliberate quantitative constraint on supply, or, rather, no mechanism to easily adjust supply to demand, and they are protected from direct competition. There is no advertising or comparisons of performance across members of the profession and they are paid an agreed upon amount for their services (rather than having to negotiate with their patients).

   2.1 Profession as a means of controlling the market of expertise

   Economists tend to see the "profession" as one aspect of the broader theme of regulation (and monopolies). As a result they do not tend to offer a definition of the profession in general (5), but the sociological literature has been concerned with such definitions. Within this discipline, professions can be defined as a means of controlling an occupation or domain of work (Johnson 1972) and this control typically involves a system of self-government, restricted recruitment and legal sanctions for a professional domain (Parry and Parry 1976, Saks, 1983). These arguments draw implicitly on Weber's theory of social closure to which he referred to the monopolization of opportunities by various social groups in order to maximize their own rewards and privileges by limiting access to them (Brante, 1988; Parkin, 1979). Parkin (1979) defined professionalism as a particular type of exclusionary closure based on credentials "designed ... to limit and control the supply of entrants to an occupation in order to safeguard or enhance its market value." (p. 54). Larson (1977, 1979) introduced the concept of a professional project which involves two interrelated closure processes of: 1) control over a market for expertise; and 2) undertaking a collective process of upward social mobility. An upwardly mobile occupation must create a need for its services and at the same time create a scarcity of resources--i.e., its own members. This is accomplished by controlling the supply of professionals by means of a standardized, mandatory system of professional training and through professional licensing and certification. Through the process of professionalization a monopoly of expertise in the market and a monopoly of status in a system of stratification are sought.

   Freidson (1970a, 1970b), implicitly drew on social closure theory in his conceptualization of professional or medical dominance. Medical dominance, he argued, is attained by establishing a powerful professional organization, by controlling the production of medical knowledge, and by the sponsorship of medicine by a societal or strategic elite that had been persuaded of the trustworthiness of the profession. Dominance consists of: 1) self-regulation over the content of medical work; 2) regulation over the terms and conditions, or context, of medical work; 3) control over other health occupations; and 4) control over clients. Expanding upon Freidson's conceptualization of professional dominance vis-a-vis other professions, Larkin (1983) introduced the concept of occupational imperialism to refer to occupation-based monopolies aimed at conserving particular skills and establishing advantageous relationships with allied groups. He described it as involving "tactics of 'poaching' skills from others or delegating them to secure income, status, and control"(p. 15).

   Building further upon this idea of an arena of tension between occupational groups, Abbott (1988) proposed the concept of a system of professions. This 'system', as he describes, is a complex, dynamic and interdependent structural network of a group of professions within a given domain of work, constantly struggling over areas of knowledge and skill expertise, called jurisdictions. A profession's success in occupying a jurisdiction reflects on the situation of its competitors as much as it does the profession's own efforts. Subordination of one professional group by another occurs when a profession vacates a jurisdiction but maintains control over it through such strategies as supervising the new 'tenant'. Audiences for jurisdictional disputes include the public, the legal system (i.e., the state), and the workplace. Both audiences and professions influence the competitive process through reshaping the profession's knowledge base and/or changing the currency of legitimation.

   In this sociological approach, professions compete for closure (and the material benefits accruing to it) and domination of related occupations who can supply close substitutes and threaten social closure. Success in getting closure and dominating other occupations is based on social prestige and connections, and these certainly explain why medical doctors managed to reach closure, dominance, and imperialism. It also explains why it is now challenged by better educated and prestigious allied health professions as well as more demanding audiences and evolving jurisdictions.

   2.2 Medical professions are more protected than other professions (not-for-profit environment and licensure): suggested justifications.

   Traditionally, economists tended to share many features of this sociological perspective agreeing that medical dominance is motivated by self interest of members of the profession rather than social welfare: professions were described as anomalies of regulation, remnants of the pre-capitalist

   past of the guilds that professions managed to keep alive due to the capture of the...