What ever happened to the Tavistock Principles and What is the consumers’ role in defining Professionalism?

Mike Magee MD

This week I continue my dive into “Advanced Professionalism”, a purposely disruptive process that explores whether it is possible to practice professionalism in a system with profound structural flaws in design, center of influence and measures of success.

A quick review. Two weeks ago I began with a list of “desirable attributes” in health professionals drawn from the University of Connecticut Health Systems website. This lead me to other lists – from the ABIM, ACGME, & ABM – of values in Medicine; which in turn led me to a classic article “A Flag In The Wind” by Thomas Inui MD, while he was a Fellow at the AAMC, in which he challenged the use of value lists and suggested medical educators ask (on behalf of themselves and their students), “What are we becoming?”

I then added the additional questions:”Why am I becoming that?” ” What am I building, where, how and for whom?” And wondered aloud, “What if our mentors are able to ‘voice’ and ‘model’ professionalism, and even appear to be ‘practicing’ professionalism, but the system itself makes it impossible for them and for their students to ‘realize’professionalism? I also injected remarks from Steven Schroeder MD, past president of Robert Wood Johnson Foundation, as well as reawakened my interest from the 80’s in W. Edward Deming.

I’ve not forgotten Deming and will comment more on him next week. The reason I delay is the Tavistock Principles. Over the past week, as part of the dive, I came upon the work of a small group of individuals led by Don Berwick, Frank Davidoff, Howard Hiatt and Donald Smith of the British Medical Association. In the late 90’s they convened a multidisciplinary group of health professionals at the BMA Headquarters on Tavistock Street in London. The meeting ultimately delivered the 7 Tavistock Principles, which they hoped would revolutionize health delivery systems from the “values up”.

In their words in 2001, “The ethicist Will Gaylin argued that healthcare reform often fails because it attempts technical solutions to ethical problems. Agreeing with this position, the Tavistock Group tried to develop ethical principles that might be useful to everybody involved in health care. They were intended for those who are responsible for the healthcare system, those who work in it, and those who use it.”

The seven principles as defined by them are:

1. A Human Right: Health care is a human right.
2. Balance Patient-Centered with Population Sensitive: The care of individual is at the centre of healthcare delivery but must be viewed and practised within the overall context of continuing work to generate the greatest possible health gains for groups and populations.
3. Comprehensively Manage Disease Burden and Promote Prevention: The responsibilities of the healthcare delivery system include the prevention of illness and the alleviation of disability.
4. Professional Collaboration: Cooperation with each other and those served is imperative for those working within the healthcare delivery system.
5. Quality Improvement: All individuals and groups involved in health care, whether providing access or services, have the continuing responsibility to help improve its quality.
6. Safety: Initially there was anxiety over “do no harm” because it is so strongly associated with doctors. But it seemed important to include because there is increasing recognition of just how much harm healthcare systems produce and of how policies with benign intentions can create harm.
7. Openness: This last principle might be both the most banal and the most profound. Nobody could argue against being open, honest, and trustworthy, and yet every day in every healthcare system people fail on all three counts.

In tandem with them the Justice in Health Care Foundation offered their list created through a similar, but more consumer oriented process:

1. Health—Health systems should pursue health as their primary goal
2. Access—Health systems should provide care primarily according to need rather than ability to pay
3. Accountability—Consumers, providers, and healthcare institutions must take responsibility for health and healthcare resources with which they are entrusted
4. Choice—Consumers must have the real ability to choose their healthcare systems, providers, and treatments in order to seek the best value in health care for themselves
5. Education—Education of consumers, providers, and institutions regarding value and quality in health care is necessary for responsible and informed health choices

They explain, “The Justice in Health Care Foundation has also produced basic principles for health care. Our group, composed of healthcare consumers, practitioners, academicians, and health system leaders, seeks to emphasise the primary importance of the consumer—the patient—in the healthcare system. Our premise is that health systems will change only if educated and empowered consumers actively and responsibly assert their needs and assertively and strategically insist that providers and systems meet these needs. We derived our principles from a different perspective from that of the Tavistock Group. The Tavistock Group began from the perspective of the provider and evaluated the behaviours that members of the healthcare delivery system should exhibit. We started from the perspective of the consumer and assessed the characteristics of a system that would best meet consumer needs.”

They go on to say, ‘We emphasise two additional concepts—choice and accountability—that reflect our consumer focus. By choice, we mean choice of health plan, of provider, and of care—as a right of autonomy and self determination. For healthcare decisions to be effective, they must be personal decisions that reflect personal values as well as medical knowledge. Accountability for the consequences of healthcare decisions is a cornerstone principle. It includes responsibilities of consumers as well as of payers and providers. Taking personal responsibility for our own health, as consumers, means paying according to our means; prudently and appropriately using limited healthcare resources; adopting health promoting behaviours; continually learning about important health issues; and actively participating in decision making about our own health as well as that of the community. This draws consumers into the healthcare system as partners, not just as payers or subjects of care. By including and preferably emphasising the legitimate needs and obligations of the consumer, we can devise and implement what the Tavistock Group referred to as ‘a clear, strong, and reasonable set of principles for conduct that all [authors’ emphasis] stakeholders who give or shape to health care can recognise and accept as guides to correct action.’ Who has more at stake than the patient?”

Clearly the Tavistock people were on the same track, albeit from a primarily provider vantage point. They said, “In a recent editorial in BMJ, several of us stated a case for a shared code of ethics that might be helpful in bringing all stakeholders in health care into a more consistent moral framework that is more conducive to cooperative behavior and mutual respect. The alternative, we suggested, was inferior: namely, separate moral frameworks, in which each discipline seeks to gain the moral high ground, failing to recognize explicitly enough that each affects the well-being of patients less as separate elements than together, as a system of interdependencies. If physicians claim to be the defenders of the “true calling” of medical care, nurses claim to defend care of the whole person, health care executives claim to be defenders of inevitably limited social resources, and so on, unity of action may suffer and, worse, the dialogue may degrade into contentiousness and mistrust among the professionals. Our patients and our society deserve better..We firmly believe that those who play any role in giving and shaping health care have shared duties and a shared mission and that we should recognize and celebrate our interdependency and commitment to cooperation in the clearest possible terms.”

What’s happen to Tavistock since 2001. I don’t know. I’ve searched, but it seems they went to sleep. In response to this week’s election in Massachusettes, perhaps it is time to wake them up again.

Next week, Don Berwick’s classic “Escape Fire” speech, and W. Edward Deming’s 14 points and 7 deadly sins.

For Health Commentary, I’m Mike Magee.