Foundation Professor of Primary Care, School of Health and Social Care, University of Lincoln, UK
Primary care has entered an era of unprecedented regulation. Paraphrasing Juvenal, ‘Quis custodiet ipsos custodes?’ will we know if regulation will be the guardian of quality and whether it leads to improve-ment rather than stagnation or even deterioration in healthcare? The regulation of the medical profession has accelerated following the Bristol and the Shipman enquiries amongst others. Recent high profile reports have set the tone for development of regulatory systems over the next century involving medical  and other healthcare professions. As changes in structure and function of professional bodies and new systems for revalidation, recertification and relicensure are being developed it is timely that this themed issue focuses on professional regulation in primary care.
The guest editors for this special themed issue, Brenda Poulton and Maxine Offredy, have assembled together a stellar cast of authors and experts and I am grateful for their efforts to create a collection of articles for thought and reflection. The authors come from a diverse group of academics and leaders who have been variously involved in researching, writing, advising on and participating in the regulatory systems of healthcare professions. Although they present a United Kingdom perspective, many of the issues and methods have international origins or implications.
Judith Allsop and Mike Saks, with their wide know-ledge of international regulation, set out the policy context for the new regulatory frameworks. They describe how increased regulation in primary care is a natural consequence of a strengthened primary care based health system, new opportunities in therapeutics, the rise of evidence-based practice and the need to contain healthcare costs. They argue that the role of regulatory agencies fits within a wider framework which includes accountability arising from clinical govern-ance as well as market mechanisms for control.
Sarah Thewlis focuses on the backdrop to current regulatory changes and how the initial focus on regu-lating medicine has moved to healthcare teams and other healthcare professionals towards a more collab-orative approach between regulators, professionals and patients. She describes how this has led to changes not only in the Nursing and Midwifery Council but also in how the regulatory bodies are themselves regu-lated by the Council for Healthcare Regulatory Excel-lence (CHRE) with the aim of producing a consistent system of regulation and revalidation across the dif-ferent healthcare professions.
Tony Butterworth argues that professional devel-opment is a necessary prerequisite for regulation to deliver quality improvement and that both need to recognise the attention given to primary and commu-nity orientated healthcare for health service reforms over the past two decades including the recent and ongoing review by Lord Ara Darzi.
Ruth Chambers describes the current work on re-certification and relicensure in the medical profession and how revalidation pilots are seeking to ensure that the system is developed to ‘enhance the quality of care and safety of patients, rather than a bureaucratic exercise for health professionals that takes yet more time and energy away from patient care’. The new system will incorporate appraisal, clinical governance and con-tinuing professional development and, although some have argued for a simpler system of regular testing, will seek to assess the performance of doctors in their day-to-day practice.
Moi Ali, herself a lay representative on the Nursing and Midwifery Council, makes the case, not only for strengthening lay participation in the regulatory bodies but enabling an equal voice for lay members and how this will inevitably lead to greater confidence in the system of professional regulation in the United Kingdom.
As healthcare teams expand and workers within them proliferate to include unqualified staff such as healthcare assistants, physician assistants and other groups, these new workers will be taking on roles previously held by professional healthcare staff. Soo Lee argues that the current educational and supervis-ory structure for at least one group of unqualified staff, primary care mental health workers, obviates the need for further regulation.
Whether the new systems of regulation will lead directly to quality improvement will be a journey through as yet unexplored territory. The challenge will be to implement systems that help us emerge into the light of public confidence without undermining public trust and professional morale. Whether a regulatory ap-proach will ever be consistent with the ‘systems thinking’ that holds the promise of real improvement and the development of constructive relationships which en-courage innovation in the health sector is another matter.
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