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Issues in General Practitioner Authority in the National Health Service

Introduction S ICAL explanation of the content of patientphysician relationships has been based on the sick role concept, with its accompanying paradigm of deviance and social control. This widely used conceptual scheme, promulgated originally by Parsons (1951), views the ill person as deviant and the medical practitioner as an agent of social control in dealing with the deviance. It is the obligation of the sick to seek expert help in order to get well, and thus to defer to professional authority in receiving and accepting information and instructions on how to end their deviant state (Coe, 1970; Butler, 1970). Authority in this context is defined as the patient's grant of legitimacy to the professional's exercise of power. The relationship with the physician is assymetrical; the patient is in a dependent and the physician a superordinate status (Suchman, 1965). It is the 'competence gap' between doctor and patient which justifies both the professional's authority and the client's trust, confidence and norm of obedience (Parsons, 1970). Although the objective of care is to return the patient to an active, independent status, he is obligated in the model to become temporarily submissive and to accept the doctor's right to tell him what to do. The sick role concept has been criticized from a number of perspectives. It appears to be applicable to acute episodes, but fails to account for chronic illness behaviour (Kassebaum & Baumann, 1974). Variations with respect to the nature of the practice setting and structure, e.g., solo versus group, or prepaid versus fee-forservice, are not accounted for (Freidson, 1961). The role of physician in conditions which may not be defined as sickness, such as pregnancy and preventive medicine, or in certain aspects of primary care, is not easily explained in terms of the model. Conflict aspects resulting from patient health education which narrows the competence gap are not considered (Bloor & Horobin, 1975). The extent to which patients evaluate and weigh physicians' instructions in deciding whether or not to comply is not included in