Introduction

Critical reflections on professional regulation have rarely taken a long-term perspective. In this chapter we draw on insights from process sociology, following in a tradition shaped chiefly by the works of Norbert Elias, in order to make sense of changes in professional–patient interactions and the implications of these changes for societal expectations of health care and the regulation of doctors. We focus this discussion on the regulatory apparatus of medical practice within England, where a shift towards increasing state involvement in regulation has taken place. This widening of ‘who regulates’ has been accompanied by a broadened understanding of quality clinical practice, with implications for ‘what is regulated’. Tensions have become apparent here between the nature of good practice as set out by the regulator and the state, and what is being evaluated in practice by current formats of regulatory assessment. To understand the emergence of these tensions as well as their impact, a longer-term perspective provides especially valuable analytical purchase, as we aim to show in this chapter.

In the section on informalisation and functional democratisation we describe various longer-term tendencies in professional–patient power dynamics – especially the development of more informal, less asymmetric relations and interactions. We then proceed in subsequent sections to consider three key implications and challenges of such informalisation, referring to changes in the practices and regulation of doctors in the United Kingdom (UK) by way of illustration. First, we argue that performances of compassion and care have become more central to understandings of ‘quality’ practice, as reflected in recent regulatory policies, but suggest that less asymmetric and structured interactions are also less stable – posing problems for quality assurance/regulation. Second, we consider that while regulators commonly seek to reflect and uphold norms and expectations regarding standards of care, the ‘softer’ less formalised features of care are harder to capture within the inevitably bureaucratic features of health care regulation and revalidation – for example, whereby professionals are required to show evidence of patient feedback, compliments and complaints. Third, we move on to explore how informalisation processes are also bound up with moves away from a blind, blanket, profession-based trust, underpinned by classic professional regulation, towards a more critical, interaction-won trust.