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Home » Research Projects » The Visible and Invisible Performance Effects of Transparency in Medical Professional Regulation

‘Do it where I can see you’

Can greater transparency in regulation improve the performance of medical professionals?

Bentham’s dictum ‘the more we are watched, the better we behave’ is often asserted as a truism. It is, therefore, no surprise that in a profession where poor decision-making can lead to a patient’s death, calls for greater transparency abound. However, the relationship between transparency and performance is not as simple as this maxim suggests.

Imagine you are a heart surgeon for whom death rates are audited and reported as an indicator of your performance. You’re faced with a patient who is almost certain to die on the operating table, but has a slight chance of survival if you perform a vital life-saving surgery. Do you operate? If you do not operate the patient will certainly die; yet, if you do, the patient will most likely die and that may prove to be a blot on your professional record.  In such a scenario the transparent audit of patient death rates creates an apparent disincentive for surgeons to take on difficult cases. Indeed, it is sometimes claimed that that the best surgeons have the worst mortality rates, for only they are willing to take on the most difficult operations.

Traditionally, medical professionals in most countries have been primarily regulated by their professional peers, yet this lack of transparency may hide poor performance. Recently there have been moves toward more standardisation and transparent auditing in medical regulation. As illustrated in the scenario above, greater transparency does not always necessarily lead to better performance. This project explores the visible and invisible effects of transparency in medical regulation, including instances where greater transparency in professional regulation may lead to ‘performance side effects’, such as perverse incentives and gaming, as well as where real gains in clinical performance result.

What the research means for policy makers and the wider community 

This study will be useful to a range of stakeholders in medical professional regulation, including:

Research Methods 

This is a qualitative study based mainly on semi-structured interviews with various stakeholders in medical professional regulation. The interviews will mostly take place in London, with approximately 15 GPs and surgeons as well as a number of NHS managers and regulators. The aim is to extract the different perspectives of each group on how transparency and regulation affect performance, as well as how each group perceives, interacts and possibly games with its counterparts. The researchers will also interview around 10 psychotherapists and counsellors, where a regulatory regime is only newly emerging, in order to compare and contrast with the more established medical profession and discover if there are any lessons that one profession could teach the other.

On conclusion of the fieldwork, the research team will convene a workshop to bring together the various stakeholders in medical regulation to discuss the provisional findings of the study and facilitate a dialogue between them. This will also present an opportunity for further data collection on the interaction amongst the different stakeholders.

Project Outputs and Related Webpages

Project poster 2009

McGivern G, Fischer M, Ferlie E, and Exworthy M, (2009) Statutory Regulation and the Future of Professional Practice in Psychotherapy and Counselling, Department of Management, Kings College London

Research Team

Gerry McGivern (King's College London)

Gerry McGivern (King's College London)

Gerry is a Lecturer in Work and Organisations in the Department of Management, King’s College London. He previously worked as a Research Fellow at the School of Management Royal Holloway and prior to that as a HR consultant to NHS, public and private sector organisations, for a technology research consultancy and a then ‘big 6’ consultancy, before undertaking a PhD on the introduction of NHS consultant appraisal and moving into academia.

Tel: 020 7848 4637

Dr. Mark Exworthy (Royal Holloway)

Dr. Mark Exworthy (Royal Holloway)

Mark is Reader in Public Management and Policy at Royal Holloway and is also a member of the Knowledge Network (measurement and evidence) which forms part of the World Health Organisation’s (WHO) Commission on Social Determinants of Health.

Tel: +44 01784 414186

Prof. Ewan Balfour Ferlie (Royal Holloway)

Prof. Ewan Balfour Ferlie (Royal Holloway)

Ewan is Professor of Public Services Management at Royal Holloway. He is also involved in an advisory capacity to a number of other organisations, including the Health Care Organisations Commissioning Panel, the NHS Institute of Health Research and Macmillan Cancer Relief, as well as being Hon Treasurer and Trustee of the Society for the Study of Organising in Health Care.

Tel: +44 01784 414366