Trust: can occupational therapists take it for granted?
Abstract: The trust that underpins the relationship between the Government, the public and professionals has been undermined, leading to proposed changes to the regulatory framework for professionals in order to strengthen clinical governance. In the National Health Service, the Knowledge and Skills Framework is suggested as a tool for revalidation, the implications of which are discussed. Occupational therapists should no longer take trust for granted, but neither is it something that can be managed entirely by legislation. Rather, occupational therapists have both a personal and a collective responsibility to re-forge public trust.

Key words: Trust, legislation, professionalism.
Article Type: Report
Subject: Occupational therapists (Practice)
Occupational therapists (Social aspects)
Occupational therapists (Laws, regulations and rules)
Occupational therapy (Laws, regulations and rules)
Authors: Mason, Rosemarie
Morley, Mary
Pub Date: 10/01/2009
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Oct, 2009 Source Volume: 72 Source Issue: 10
Topic: Event Code: 200 Management dynamics; 290 Public affairs; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 210596134
Full Text: Introduction

Trust is a complex concept, having symbolic connotations for professionals. In 2007, the Government published a White Paper entitled Trust, Assurance and Safety (Department of Health [DH] 2007). This proposed changes to the regulatory framework for health professionals in the United Kingdom, highlighting the importance of trust within the relationship between professionals, their clientele and the Government. Any regulatory framework takes into account the idea that confidence in the trustworthiness of health care workers is justified. To some extent, such confidence has been compromised through tragedies such as that perpetrated by Shipman (Smith 2004). The White Paper prompted the consideration of the implications of trust within the context of professionalism and specifically for occupational therapy.

Trust within society

According to most authorities, professionals and the ideal of trust have been synonymous (Millerson 1964). They are 'professing' to be people of integrity (Moline 1986). This claim may be based on a vow (the Hippocratic Oath, for example) or a code of ethics (Hughes 1963).

Trust serves a number of functions for professions. Health professionals have access to privileged information from a vulnerable clientele. Clients will only make disclosures on the understanding that the information is needed to resolve the problem and will be treated confidentially. Professionals must be trusted not to abuse such disclosures (Becker 1977, Hughes 1981, Moline 1986). Such a commitment underpins a social contract between professions and society, which then grants the profession a monopoly over its knowledge base, the right to autonomy in practice and the privilege of self-regulation (Abbott and Meerabeau 1998, Cruess et al 2004).

The professions won this right by persuading the State that competence and trustworthiness could be guaranteed (Wilding 1982, Freidson 1994). Under these circumstances, the State sanctioned individuals who were certified with the appropriate qualification to appear on an official register; hence, an overt stance on trustworthiness has permitted only registered occupational therapists to be able to practise within the United Kingdom.

Recently, the State and the public have demonstrated dissatisfaction with professional behaviour and a decline in levels of trust (Swick 2000, Bruhn 2001, Cruess and Cruess 2006, Stark et al 2006, Kell and Owen 2008). The Government had attacked the power and autonomy of the professions (Foster and Wilding 2000), seeking to deliver a consumer-focused National Health Service (NHS). There was a strong political interest to ensure public safety, leading to new statutory responsibilities for clinical governance (DH 1998). These reforms were only partially successful (Humphrey 2001). Professional self-regulation was insufficient to ensure high standards and, therefore, further reforms were needed (Ham 2004, Klein 2006).

Revalidation

The Bristol Inquiry (Kennedy 2001) introduced mechanisms to safeguard the public, such as appraisals to limit the autonomy of practitioners, although the medical profession retained some collegiate self-regulation. The Shipman Inquiry (Smith 2004) argued that the General Medical Council still favoured its members' interests over those of the public. The Government therefore proposed changes to the regulatory framework for health professions (DH 2006) and a radical transformation of the General Medical Council's remit: removing its judicial role and control of medical education and undermining self-regulation (Klein 2006). Alongside this were proposals for the revalidation of nurses and health professionals, encompassing fitness to practise and continuing professional development (CPD):

This marked a significant change, with implications for all professionals. Trust, embodied within a code of ethics, has been the defining characteristic separating professions from occupations (Moline 1986, Abbott 1988, Harrison and Pollitt 1994). The belief that a profession encapsulates a culture that ensures that its members will act in the best interests of society is essential as a marketing commodity (Larson 1977). However, trust is now becoming something that is legislatively imposed rather than being inherent within the culture of the profession itself. The White Paper (DH 2007) builds on the current arrangements, whereby every 2 years registrants sign a professional declaration that they continue to meet the Health Professions Council's (HPC) standards of proficiency; that there have been no changes to health or good character that would affect the safe and effective practice of the profession; and that they continue to meet the standards for CPD (HPC 2008).

The new proposals suggest that for the majority of occupational therapists employed by the NHS, evidence to support revalidation will be provided through appraisal systems using information gathered under the Knowledge and Skills Framework (KSF) as part of clinical governance systems (DH 2004, 2007). The KSF is a competency framework introduced through Agenda for Change, the revised employment contract for most NHS staff (DH 2005). This developmental tool sets out the knowledge and skills required for each post, with the aim of modernising practice and improving patient care, but does not address attitude explicitly. The proposals raise a number of issues for occupational therapists to consider, both those within the NHS who have the KSF and those in non-NHS employment or private practice who are regulated by the HPC.

An emphasis on skills competency may lead to a cookbook-type delivery of health care (Kell and Owen 2008). Professional work involves not only a series of technical processes but also elements of interpretation and judgement (Abbott 1988, Macdonald 1995). Other professions have noted that external control undermines professional artistry (Kell and Owen 2008), leaving little room for the service ethic or professional dedication (Jewell 2005). The focus on competency within the KSF limits its use as a tool to revalidate fitness to practise within the broader definition provided by the HPC. This reinforces the belief that fitness to practise is more than just technical ability, defining it as the combination of conduct, 'skills, knowledge, character and health' to practise safely and effectively (HPC 2006, p2). However, the KSF may be used as a tool to provide evidence of the application of knowledge and skills and of ongoing learning to support the revalidation process.

Implications of the KSF

The implementation of the KSF across the NHS has been slower than anticipated and this raises questions about the proposal for its use for the revalidation of NHS staff (Buchan and Evans 2007). The National Audit Office (2009) reported that by September 2008, 54% of staff had had a knowledge and skills review, following ministerial support for its relaunch. The National Audit Office's (2009) report confirmed that the KSF was key to realising many of the benefits from Agenda for Change more widely and made recommendations to assist its implementation. Widespread implementation is necessary to support the Government's proposals to use the KSF to support the revalidation process for NHS staff (Chief Medical Officer 2006, DH 2007). Assuming that the KSF continues to be rolled out, it is timely to consider the need for stringency in the collation of evidence of professional knowledge and skills, the structures to support this and the personal responsibility that individual practitioners share.

The KSF is a competency framework against which a practitioner's knowledge and skills are reviewed annually. This development review has been largely integrated into existing appraisal systems that are an established part of practice in most employment settings. Practitioners provide evidence that they have the requisite knowledge and skills across dimensions such as communication, quality and service improvement, as well as clinical competence. Evidence for the KSF development review, therefore, can be used to illustrate artful practice, as well as to show that CPD has contributed to the quality of practice and service delivery with benefits for the service user, which forms part of the HPC CPD standards (HPC 2005).

In preparing evidence, occupational therapists should take account of these standards, thereby making explicit their professional commitment to service. Managers, when reviewing this evidence, can assist this process by testing the evidence not only against the KSF but also against these standards. By reconsidering evidence in this way, occupational therapists may be able to move beyond the technical requirements of the KSF and to ensure that CPD demonstrates accountable practice that is linked to continuous improvement rather than just quality control. Those not employed in the NHS could also conceptualise evidence from this perspective.

Conclusion

This discussion emphasises that professionalism is not determined just at policy level and that individual practitioners have an equally important contribution. Professionalism is expressed through policy formulation at organisational level. At practitioner level, individuals make the concept of professionalism manifest through their behaviour and interactions with society (Richardson 1999, Mason 2006). Each practitioner carries professional accountability to serve the public and to expand his or her knowledge and skills (Eraut 1994). White and Begun (1996) have suggested that in being accountable to stakeholders rather than self-regulatory bodies and through serving societal needs by demonstrating effectiveness, practitioners can contribute to a modern form of professionalism. When occupational therapists provide evidence that they have combined technical skill and professional artistry in a way that ensures continued service improvements, they contribute to the collective presentation that this is a profession that can be trusted to modernise in accordance with the needs of society.

Submitted: 11 November 2008.

Accepted: 26 May 2009.

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Corresponding author: Dr Rosemarie Mason, Lecturer, School of Allied Health Professions, University of East Anglia, Queen's Building, Earlham Road, Norwich NR4 7TJ. Email: r.mason@uea.ac.uk

Reference: Mason R, Morley M (2009) Trust: can occupational therapists take it for granted? British Journal of Occupational Therapy, 72(10), 466-468.

Rosemarie Mason (1) and Mary Morley (2)

(1) University of East Anglia, Norwich.

(2) South West London and St George's Mental Health NHS Trust, London.
Revalidation is a mechanism that allows health professionals
   to demonstrate that they are up-to-date and fit to practise
   (DH 2007, p31).
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