Medical school field as a whole meso-level master frame

Moving up from the individual organisations to the medical school field itself, a single encompassing “master frame” clearly emerged - the only framing on which all respondents agreed, which I have called the compliance/influence frame. The logic of this PPI frame is so simple no matrix is presented: The key unifying diagnostic element was the GMC's concern regarding the lack of lay involvement in curriculum governance and design; the responsibility rested with the GMC, as regulator, for making this a regulatory requirement in Tomorrow's Doctors 2009. Thus the medical schools’ solution was to have lay members on committees. Their motivations were mixed - but were aligned on the simple need to comply. Every medical school respondent had understood that medical schools were expected to be able to provide evidence of compliance, through committee Terms of Reference (ToRs), membership lists and minutes. Concern regarding a school's ability to demonstrate compliance if requested was expressed by many. What varied was the moral evaluation of this perceived requirement, as illustrated by the following vignettes.

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Further tales of committees: PPI in Student Health & Professional Conduct hearings

The contrasting framing of committee membership as (a) compliance with GMC requirements70. or (b) an independent voice - bringing lay knowledge and challenging medical authority are further illustrated in the events described in box 5.10

Table 6.10: Field Vignette Anglebury Medical School - PPI in student conduct hearing

A1 Head of School A4 QA Lead A5 PPI Lead

Frame: Compliance Compliance Influence

[there was ] a lay participant in a Fitness to Practice hearing ... And he was very useful I think, ... he came from a sort of health charity background so was really a sort of expert lay person, well informed... My colleagues who were presenting the case for the student to be suspended felt somewhat aggressively cross-examined by that person - I explained... my colleagues didn’t need to take it personally, it was just the duty of the person on the committee to ensure that the student had been supported and hadn’t been disadvantaged by any sort of lack of .. appropriate guidance from the medical school. But anyway what struck me is they (lay reps)... seemed to think that the medical school ought to be sort of in loco parentis for this young man... whose fitness to practice was being considered ... and didn’t really have an understanding of the fact that we were not paternal and that he was an adult learner, he had to adhere to the standards that were set by the GMC for the behaviours and attitudes of medical students as well as doctors, and they [ the rep] weren’t informed about... you might say [student] life style choices.

if you take the example of … as I said, we had lay involvement in the fitness to practice panel, and it was incredibly difficult for that lay person to scrutinise in the way that we needed them to scrutinise. You know it was … yeah … [Challenging ]. And you know potentially caused more problems than the benefits we accrued from having that lay involvement.

And I feel had that person you know been involved in some of the committees that had looked at the original fitness to practice policy, that talked regularly about the GMC’s expectations for fitness to practice, they would have had a context that would have then enabled them to direct their scrutiny appropriately and fulfil the function we needed them to fulfil more effectively.

Yes, yes. What has subsequently happened though is one member sat on a Fitness to Practice... and did anecdotally a fantastic job in doing what they should do … but I think probably the expectation that somebody might just sit there and not say anything (laughs) was not actually what happened.

70

Health & Conduct Committees (formerly Fitness to practice, FtP) consider a student's "fitness" to continue studying , with or without restrictions/sanctions, in the face of unprofessional or concerning conduct. Health and Conduct Hearings are governed by guidance produced jointly by the GMC and the MSC, to coincide with TD09. Students should have a supporter (often a pastoral tutor) and the panel should include (inter alia) : a. someone from outside the medical school; b. someone with legal knowledge; c. a student representative who does not know the student being investigated; d. a doctor registered with the GMC. All members should be trained and act without bias. http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp

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This event, related from three different perspectives, explores the extent to which a lay presence in governance structures may be expected to, or even permitted to, challenge clinical academic authority. A5, as we would have expected from her primary frame discussed above, considers active participation to be the core purpose of a lay presence. No doubt she had heard that her lay representative colleague had been considered "challenging" and this aligns with the discourse of underlying the "influence/rights" frame(Table 6.4 above). The framing logic is that appropriate scrutiny is achieved through the use of lay knowledge which can challenge authority. At Anglebury, A5 recruited representatives on the basis of their "patienthood" and humanity which confers their required expertise. A1 and A4, on the other hand, share an aligned "compliance" frame, although they use different logics. For A1 , the lay representative failed to understand a fundamental need to comply with the GMC - for the medical school, and the individual student; for A5, the reps need to "fulfil the function we needed them to fulfil " - that is scrutinise rather than "challenge" - and this requires greater policy awareness. We can contrast this with the situation at Casterbridge Medical School. (Box 6.11)

Table 6.11: Field Vignette Casterbridge Medical School - PPI in Student conduct hearing

C 1 Head of School C 2 Head of Programme

… on all the committees because I’ve always found lay people really helpful .. I really wanted them on Conduct [committees] Because you can see so much collusion happening there with students who come round again and again, and many times I thought crikey, if we had

somebody who was representing a lay view, they would say ‘For Christ’s sake, you don’t want this student, they’ve had three psychotic breakdowns, what are you doing?’

….on our health and conduct, our former fitness to practice committees, we have people on our progress committees. And interestingly, amongst the people we appointed there are people who have specific and extraordinary medical stories, but part of what we explored when interviewing them was - was that the only thing they were interested in? ... and it wasn’t. And so I was on the committee last week with someone who’d had X problems, and a transplant, all sorts of things, and that never seems to directly influence how he contributes to the committee that he’s on.

Rather than the language of compliance, C1's framing of this type of PPI representation overlaps with the influence frame. Here the application of lay knowledge and authority - as was probably intended by the GMC - is used to break collusion between the clinical academic and a student they may already feel some professional (or pastoral - it's not clear) allegiance to71. As C2 explains, in this variation of the frame, authority is conferred by being a lay person

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It should be noted that Health and Conduct Hearings are governed by guidance produced jointly by the GMC and the MSC. Students should have a supporter (often a pastoral tutor) and the panel should include (inter alia):

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who is selected precisely because s/he is able to leave her/his patienthood and suffering to one side. This is very different to the epistemic authority valued by A5 (the PPI lead at Anglebury).

These two vignettes draw attention to some of the subtle findings regarding the effect of making lay representation on such committees a regulatory requirement. The moral or justice dimensions of this type of social governance highlights the tensions between the lay member's duty to the medical school, and the GMC (the professional priorities) on the one hand, and to represent wider society, on the other. In the middle is the uncertain duty to the individual student, in transition from lay person to professional.

At a practical level - what is "the deal" here and how, when, and by whom should 'the deal' be struck? The idea of lay-patient-public and of knowledge-authority are considered later as meta frames. First, I need to share my findings from the regulator case study. If, amongst the many framings of PPI across the medical school, the single master frame was that of compliance through lay memberships on committees, how did this relate to the frames at the level of the regulator?