Challenging medicine: how to influence the agenda in foot surgery

Challenging medicine: how to
influence the agenda in foot
surgery
Dr Alan M Borthwick, University of Southampton
27 th October 2012

Foot surgery: medical opposition
o Medical dominance
o Cultural authority
o Social authority
o Professional autonomy
o Technical
o Political
o Economic (Elston 1991)
2

Foot surgery: medical opposition
o Medical dominance
o Subordination
o Limitation
o Exclusion (Turner 1995)
3

medical opposition: modes & transition
o Formal expressions of disapproval (profession to
profession)
o Attempts to eliminate (appeal to state)
o Attempts to incorporate (delegate and control)
o Attempts to limit (eg. title)
o Attempts to undermine in public arena (“misleading”
public)
4

Mr. Ronald Laxton, founder of podiatric surgery in the UK

Croydon Postgraduate Group 1968-1974
o
Croydon Postgraduate Group devised a system of postgraduate education:
initially ‘functional’ anatomy, ‘interpretive’ radiography and ‘skin surgery’
(1970)
o
Assisted by a range of supportive medical professionals:
o “I am impressed by the depth and span of your teaching programme…I
would be pleased to help with the postgraduate group”
(E Maelor Thomas, King’s College Hospital, per com to Laxton R, 17 th January 1973)

Croydon Postgraduate Group 1968-1974
o Dr. Jack Powers ‘DPM’ of Stockton, California demonstrated:
o nail wedge resections with galvanic current and
o hammer toe corrections in 1970 in London, Poole, and Colchester:
o “two technique man”
o Croydon Group members undertook first bone procedures (hammer toe
correction) in 1971 under Jack Powers.
o Growth in postgraduate groups emulating Croydon Group 1971-1973

Podiatry Association (1974)
All UK postgraduate groups merged to form national
‘Podiatry Association’ (1974)
Establishes national educational framework:
‘certificate in podiatry’ with
examinations and pupillage system
Association specifies key standards for practice, including
consultant surgeon as examiner and a required ‘inspector’
of theatre premises

Podiatric Surgery and the NHS
Margaret Thatcher and the ‘New Right’ (1979)
free market economy and ‘competition’
anti-professional/ ‘anti-monopolistic’
Managerialist Agenda: Griffiths reforms empowered general
managers to select services on basis of clinical effectiveness (through
audit), cost effectiveness and accessibility (‘best value’) (1983)
Orthopaedic ‘failure to satisfy demand’ for foot surgery created
opportunities for competitive services – growth in NHS podiatric
surgery (Sharrard 1982; Bell 1982; BOA Newsletter Autumn (November)
1981:1-2; )

Podiatric Surgery, RCS and BOA: ‘jurisdictional disputes’ (Abbott 1988)
RCS wrote to regulatory Board ‘chiropodists should be
allowed to operate only upon the skin of the foot and those
structures (callosities and toenails) which derive from it’
(January 1980)
SCP commented ‘it is for the Society and the Chiropodists
Board to define the scope of practice of its members’
(January 1980)
RCS established Working party on
‘Chiropodial Surgical Practice’ (1983)

Podiatric Surgery and the CPSM
o By 1986 Regulatory Body (CPSM Chiropodists Board)
recognised
o Designatory letters of qualified podiatric surgeons on Register
o ‘Ambulatory Foot Surgery’ recognised within the Statement of
Conduct for Registrants

Podiatric Surgery and the NHS: integration
1990s ‘Internal market’ (managed market) provides added opportunities:
competitive tendering
GP fund-holding
Quality standards in NHS: ‘cost, quantity and quality of care’ in
contracts including waiting times, patient satisfaction, clinical audit
with accountability to purchasers – managers or GP fund holders (Ham
1994; Flynn et al 1996)
PA data forwarded to DoH on day care surgery, discharge rates, surgical
outcomes, and advantages over ‘traditional’ chiropody foot care (eg.
Tollafield 1993; Turbutt 1993)

Podiatric Surgery and the NHS : integration
GP fund holders purchase podiatric surgery services: “GPs praise
podiatry” GP journal published report which ‘praised’ podiatric surgery
as cost-effective accessible service with excellent outcomes (1995)
(General Practitioner, 24 th February 1995; Milsom 1995)
Medical audit on orthopaedic and podiatric forefoot surgical services :
found “comparable” performance on forefoot surgery and “generally
supported the recognition of surgical expertise of podiatrists”
(Laxton 1993, 1996)

Podiatric Surgery and the NHS
DoH ‘Feet First’ document promoted podiatric surgery on grounds of
evidence of effectiveness, cost, access, supply and demand issues
(1994)
1991-1993 RCS Commission on the Provision of Surgical Services
Working Party on foot hospital services:
“podiatrists with appropriate postgraduate training (FPodA) will
provide an ambulatory foot surgery service encompassing a range of
procedures on structures distal to the malleoli…” (Report
unpublished, minority report 1995)

Podiatric Surgery and the COPSS report (1995)
“…well, no one was arguing about their expertise, that was accepted,
but…”
“…Council would not approve it [for publication] as it [did not] clarify
who should run it…we wanted to ensure the influence and standards of
the Royal College of Surgeons”
(Members of Council, Royal College of Surgeons, 1996)

Podiatric Surgery and the COPSS report (1995)
“if the orthopaedic surgeons did not provide the service it’s no surprise
people looked elsewhere for it.. One would hope that approval would
come from the Royal College of Surgeons. There are already Faculties
in the Royal College that encompass non-medically qualified
people…where those other than the medically qualified can be
associated with the Royal College of Surgeons”
(Member of Council, Royal College of Surgeons, 1996)

Podiatric Surgery and the NHS: the DoH
A Department of Health view (1996):
“…it’s access that, I think, has won the day. Cost ultimately will creep into
it, but…it’s been accessibility…the waiting list for podiatric surgery is
three months and no longer. In orthopaedics the average is way beyond
patient charter norms”

Podiatric Surgery, the RCS and JCC
Key issues of contention (1996-7):
use title ‘consultant’
Use of title ‘podiatric surgeon’
Consent from patients to surgery by
podiatrists

Podiatric Surgery and the NHS: the medical backlash
RCS, JCC and BMA undertook new campaign to
instigate ‘delegation’ as an alternative to ‘elimination’
(1996)
BMA challenged use of title ‘podiatric surgeon’ as
contravention of Medical Act (1983) (1996)
RCS challenged of use title ‘consultant’ claiming title
protected by statutory instrument (1996)

Podiatric Surgery and the NHS
o PA agreed malleoli as limit to practice in COPSS negotiation (initially)
(1995)
o RCS attempted to assert right to ‘govern’ foot surgery by Royal Charter:
no such provision in charter (only ‘promotion’ with members)

Podiatric Surgery and the NHS: Government response to medicine
• DoH regarded BOA / RCS moves as ‘monopolistic’
• JCC (1996) publication seeks ‘medical delegation’ of surgery by nonmedically
qualified = technician status

Podiatric Surgery and the NHS: ongoing change
‘New’ NHS agenda : retained purchaser/provider split &
‘modernisation’
Reconfiguring the workforce (Cameron and Masterson 2003):
‘breaking down traditional barriers’ &
‘working across traditional professional boundaries’
‘new ways of working’ - expanded roles for the AHPs

Podiatric Surgery : myths & realities
“I graduated 1991, FPodA in 1997, CCST in 2002 and Consultant in
2004. The pass rate with Part A was approx. 20-30% each year, with
10% passing on first attempt”
(McCulloch 2007)
“They started off with bunions, now they are doing tumour surgery and
even ankle replacements…”
(Freudmann 2004)

Podiatric Surgery and the ‘New’ NHS: illustrative statistics
In 1999 22,500 foot operations by podiatric surgeons (excluding
minor nail procedures) (Graham 2000)
In 2000
21 Consultant Podiatric Surgeons in post
46 Specialists in Podiatric Surgery
54 NHS Trusts with Podiatric Surgery service (Graham 2000)

Podiatric Surgery and the ‘New’ NHS: illustrative statistics
In 2012
55 Consultants in post
160 Podiatric Surgeons on register
(SCP register 2012)

Podiatric Surgery
• RCSEd and RCS&P (Glasgow) & SCP “joint diploma” in
podiatric surgery 2001
• ‘it 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…ensure that those
podiatrists were not autonomous but worked in multidisciplinary
teams’ (Royal College of Surgeons of Edinburgh
2001).
• Glasgow Caledonian/Queen Margaret University College
Edinburgh 2004 MSc in Theory of Podiatric Surgery

Key issues
• Annotation of podiatric
surgery
o SETs
o SOPs
• Any provider may supply
education & training if
HCPC standards are met
• RCS and BOA to be
consulted by HCPC on
setting standards (public
consultation)
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Key issues
o Public campaign to
discredit podiatric surgery
o ‘misleading the public’ &
loss of Department of
Health support
o ‘wilfully and falsely’ using
title ‘surgeon’
28

Key issues
• acknowledge podiatric surgeons as independent ‘restricted to the toes’
• recognise that ‘the term ‘consultant’ was not a protected title
• the term ‘surgeon’ could be ‘variously applied but misleading (Macnicol
2007). (BOA President)
29

2004 – the media war begins
o British Orthopaedic Trainee’s Association ‘declared open war’ on
podiatric surgeons, claiming that they had ‘no medical qualifications at
all’ (Hawkes 2004)
o 95% in public survey were said to have believed that a consultant
podiatric surgeon was ‘medically qualified’
o “we have repeatedly complained, but we get no help from the General
Medical Council, and absolutely none from the Department of Health
[which] thinks podiatric surgeons are wonderful because they are quick
to train, cheap, and take patients off orthopaedic waiting lists” (BOA
President)
30

2008 - 2009
o the Telegraph : podiatric surgeons ‘confusing’ patients
(Devlin 2008),
o 2009 The Times : questioning the competence of
podiatrists to practice surgery (Davies 2009).
o BBC London television : 7 th December 2009 (Ahmad 7th
December 2009):
o reported an expression of concern by the Department of Health
about the use of the title ‘surgeon’ by podiatrists
o Health Professions Council assured BBC it would ‘review’ the use of
title by podiatrists
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2010 - present
o ‘misleading’ to combine to two terms ‘consultant’ and ‘surgeon’, The
Telegraph (Getty 2010)
o Department of Health contacted the Society of Chiropodists and
Podiatrists in 2010 to express its concern, and to suggest alternative
titles that the Department would be prepared to accept
o 15 th July 2012 BBC News: RCS calls on Government to legally protect
title surgeon to those who are ‘medically qualified’
o Earl Howe (Minister for Health) ‘refuses’ to meet SCP ‘until resolution
of issue on title’
32

2010 - present
o DH asked to provide assurances, if title was changed on:
o Annotation
o Specialty coding
o Insurance liability if title changes
33

2010 - present
o Outcome to date:
o Annotation: attained at CCPST level (independent)
o Specialty coding : new coding systems to be introduced
o Insurance liability if title changes: ‘negligible’
34

Faculty of Podiatric Surgery EGM September 2012
o Acknowledge ‘support’ of DH and ‘concern’ over title
o Wishes to await enactment of HCPC annotation before
considering changing title
o Wishes to seek DH ‘assistance’ to introduce measures to
ensure patients are not ‘misled’ or ‘confused’ – mandatory
and regulated
35

conclusions
o Medical dominance attenuated
o Podiatric surgery isolated – need to lobby support of DH
o Foot surgery continues to be a ‘hot boundary’: workforce
redesign potent argument
o Abbott (1988):Jurisdictional dispute
o Public, political and workplace audiences
36

Thank you for your attention
37