west midlands central health innovation and … · 2 wmc hiec education theme report 1 abstract: we...

2 WMC HIEC Education Theme Report 1

Education Theme

Continuing professional development: Accountability, autonomy, efficiency and equity in five professions

Authors:

Hywel Thomas

Tian Qiu∗

Centre for Research in Medical and Dental Education, School of Education,

University of Birmingham, Birmingham, UK.

∗ Corresponding author. Tel: 0121 414 7604, Email: [email protected]

WEST MIDLANDS CENTRAL HEALTH INNOVATION AND EDUCATION CLUSTER

(WMC HIEC)

mailto:[email protected]

1 2 WMC HIEC Education Theme Report 1

ABSTRACT: We examine the influence of neo-liberalism in re-shaping the

accountability of five professional groups (accountants, solicitors, social workers,

nurses and doctors) and its consequence for their CPD policies. Documentary

analysis and Quarterly Labour Force Survey data (n=31,260) from the 1990s to the

present are integrated in a comparative method which examines whether changes

are specific to a profession or represent more general patterns.

Using complementary theories from neo-liberal economics and the sociology

of professionalism, we show how regulatory oversight has altered

accountabilities. Its consequence for the autonomy of professions and

individuals in determining CPD requirements differ between the five groups,

mediated by status, public concern, regulator activism and, possibly,

alignment with the financial sector. Efficiency and equity are analysed using

theories of professional learning and human capital. Wider economic

conditions influence the incidence of CPD with recent years showing declining

participation; we also show changes in ‘what counts’ as CPD and its greater

integration with performance management. Findings on selected equity

criteria are also reported. Some regulators are becoming more specific about

the content of CPD, while others are defining what constitutes good practice

and requiring its use in planning CPD. Greater attention is being given to

issues of ethics and probity.

Keywords: continuing professional development, training incidence,

accountability, efficiency, five professions


1. INTRODUCTION How has the ascendancy of neo-liberalism (Klein, 2007) and the ‘market triumphalism’

(Sandel, 2012) of the last three decades shaped frameworks for continuing professional

development (CPD), and with what consequence? From Thatcher to Blair, we are familiar

with the use by British governments of privatisation, quasi-markets, competition and target-

setting as means of challenging the autonomy of public service professionals (the so-called

‘producer interests’) so as to improve their responsiveness to consumer and client

preferences and, thereby, the effectiveness and efficiency of ‘service delivery’ (Le Grand,

Propper et al., 1992; Le Grand, 2003). Less directly examined is how neo-liberalism also re-

shaped the regulation of professional bodies, in both private and public sectors, and its

consequence for the autonomy, efficiency and equity of the CPD of individual professionals.

We first ask how regulatory oversight was altered and with what consequence for

requirements for CPD? We then ask what the changes have meant for the efficiency of CPD

and whether there has been any impact on equity of access to CPD?

We begin with a description of the five selected professions and the reasons for our

choice. The second part examines those features of neo-liberalism that led to changes in

regulatory oversight and the accountability of the five professions. Its consequence for how

CPD requirements changed is then analysed with ideas from the sociology of

professionalism complementing the neo-liberal perspective and explaining how levels of

autonomy in setting those requirements differed between the five groups. The third part

applies theories of professional learning and human capital to analyse evidence on the

efficiency and equity of CPD. Efficiency is assessed with evidence on levels of participation,

whether ‘what counts’ as CPD is consistent with contemporary ideas on modes of learning

and whether patterns of participation are consistent with human capital theory. Our equity

criteria are derived from the data in the Quarterly Labour Force Survey (QLFS). With

evidence from the 1990s to the present, our comparative method illuminates whether

changes are specific to a profession or represent more general patterns.

2. FIVE PROFESSIONS

We selected accountants, solicitors, nurses, social workers and medical practitioners

(doctors, hereafter). In terms of longevity as legally recognised self regulating groups, three

have prima facie higher status: in 1845, a Royal Charter established The Law Society as the

governing body for solicitors (Law Society, 2008) while the Society of Accountants in

Edinburgh received its Royal Charter in 1854 (ICAEW, 2012b) and the General Medical

Council in 1858 (GMC, 2012b). Nursing might also claim some longevity as it was first


regulated in 1919 (National Archive, 2004) but social workers became a registered

profession only in 2001 (GSCC, 2004).

With data drawn from the Quarterly Labour Force Survey, 1995-2010, following

guidance to avoid duplication (Rafferty and Walthery, 2011), Table 1 shows accountants,

solicitors and doctors are much more likely to hold degrees and be self-employed, consistent

with traditional profiles of status. They are also more highly paid than social workers and

nurses. Our data shows the mean of gross weekly payi adjusted for inflation using the

Consumer Price Index (CPI) and in 2010 prices, the smaller number of respondents arising

because questons on pay are asked less frequently. These three groups also have higher

proportions of males than social work and nursing, although the changing gender mix

between 1995 and 2010 is substantial across all groups, except nursing.

Table 1: Profile, QLFS, 1995-2010 % Accountants Solicitors Social workers Nurses Doctors Public 1995-2010 11.3 10.4 83.3 81.9 66.6 Employees 1995-2010 72.7 61.5 97.6 99.1 72.0 Degree 1995-2010 64.1 92.7 48.8 18.6 88.9 N 4466 3189 3186 15670 4749 Male 1995 81.9 66.1 19.4 8.8 68.7 2010 63.2 55.2 28.3 9.1 54.8 1995-2010 70.4 59.9 25.5 9.1 59.7 White 1995 93.0 96.6 90.5 92.7 78.3 2010 87.0 89.6 82.3 85.2 66.2 1995-2010 90.4 92.1 88.9 88.5 72.8 Gross weekly pay

1997-2010 644 769 441 384 930 N 2046 1264 2071 10654 2251

We compare policies in the private and public sectors by including two private-sector

dominant groups, two public-sector dominant with doctors as a hybrid, as its general

practitioner (GP) members are technically part of the private sector although, through

contract, almost all their work is for the National Health Service (NHS).

Including social workers and doctors also provides an additional perspective, as

groups with different status but sharing recent histories where public confidence has been

weakened. For social workers, concerns were raised by the deaths of two children, Victoria

Climbié in 2000 and Peter Connelly (Baby ‘P’) in 2007, leading to major inquiries and reports

(HM Treasury, 2003; Laming Report, 2003; Ofsted, 2008; LCSB Haringey, 2009)

recommending changes in the management of social work and the governance of the

profession. In medicine, concerns about both clinical competence and failures to address

them arose earlier. For example, the Bristol Royal Infirmary Inquiry not only raised concerns


about clinical competence from high levels of mortality in paediatric surgery but also the fact

that these concerns had been raised but set aside many years earlier (Bristol Royal Infirmary

Inquiry, 2001). A similar failure to act on evidence of ‘serious failures in clinical practice’

(DH, 1999) emerged in 1996 in relation to a gynaecologist in South Kent Hospitals where

concerns had existed since the mid-1980s (Ritchie, 2000). Together with the Shipman case

(The Shipman Enquiry, 2003; The Shipman Enquiry, 2004) and the Alder Hey ‘body parts’

scandal (Royal Liverpool Children’s Inquiry, 2001), these contributed to public concerns both

about clinical competency and transparency.

In turning to examine changes in the accountability and autonomy of these five

professions, much is owed to the ideological influence of neo-liberal economics but pertinent

to understanding how different groups responded to these influences are sociological

analyses of professionalism.

3. ACCOUNTABILITY AND AUTONOMY

Neo-liberal economics and regulatory oversight

Drawing upon the work of Hayek and Friedman (Hayek, 1944; Friedman, 1962), neo-liberal

economics is premised not only on the virtues of markets as a means of providing goods and

services but the negative impact of state and non-state restrictions that inhibit freedom of

exchange between consumers and producers. On the latter, it echoes Adam Smith’s

observation that ‘People from the same trade seldom meet together, even for merriment and

diversion, but the conversation ends in a conspiracy against the public, or in some

contrivance to raise prices’ (Smith, 1776). Worse, in its modern guise of occupational

licensing, state and producer interests combine to the disadvantage of consumer. In a

trenchant critique, Friedman (Friedman, 1962) defines them as the modern version of the

medieval guild whereby the state assigns powers to a profession which, among other

benefits, uses them to restrict access, boost salaries and make legal challenge on grounds

of incompetence more difficult. As this critique embraces activity in the private as well as the

public sector, it goes wider than the focus on the state sector in public choice economics

(Buchanan, 1969; Buchanan, 1979; Mueller, 1989).

The critique of licensing is that its mandatory nature serves the interests of the

occupational group, who may benefit from increased income and demand because of

perceived improvement in the quality of the service provided, and also the interests of

governments, who are seen as acting to protect the quality of services available to the

public. However, the benefits for clients and consumers are less certain: we can reasonably

assume that restrictions on the supply of labour will push up quality but, as it also pushes up


price, it cannot a priori be predicted whether licensing will improve or degrade the

price/quality ratio (Kleiner, 2000) and empirical evidence is mixed (Maurizi, 1974; Kleiner,

Kudrle et al., 2000; Angrist and Guryan, 2008; Humphris, Kleiner et al., 2010; Kleiner, 2011).

More influential than the quality of evidence, however, is the influence of these neo-liberal

ideas on UK governments and leads to our first proposition:

To the extent that the state develops its policies within the perspective of neo-liberal

economics, we might expect policies that weaken professional monopolies or, if this is

deemed not feasible (e.g. possibly for certain areas of medical practice), devise

stronger regulatory systems.

An overview of all five professions shows their regulatory regime has been altered

since the early 1990s. For accountancy, changes in 2001 and 2003 separated monitoring

and representative functions. Monitoring is now overseen by The Financial Reporting

Council (FRC) with a remit for accountancy standards and including ‘promoting high quality

corporate governance’ (FRC, 2012a). Its 15 members are ‘largely drawn from senior figures

in the business, professional and financial community’ (Gray and Manson, 2011) with 11

members from the financial sector, one lawyer and three former civil servants (FRC, 2012b).

Unlike changes to the other four professions, the distinction between professional and lay

members of the Council is unclear and raises the question whether accountants have

benefitted from the ‘light touch’ regulation that has characterised the financial sector since

the 1986 financial ‘Big Bang’. Indeed, the Council and its subsidiary bodies have been

criticised for too little scrutiny of the profession and its acceptance of working practices that

threaten conflicts of interest, particularly whether audits by the ‘Big Four’ accountancy firms

(PwC, Deloitte, Ernst & Young and KPMG) were influenced by the scale of their non-audit

business with the banks (Sikka, 2009; HC, 2009a; HC, 2009b). Proposals to remove a

current requirement to consult with the professional bodies during any disciplinary process,

however, suggest a move towards greater independence (FRC, 2012c).

Until 2007, solicitors were classically self-regulating as The Law Society which was

both the profession’s regulator and representative body. Following a report in 2004

(Clementi, 2004), the Legal Services Act, 2007 created a new regulatory environment for

lawyers, regulation of solicitors moving to the Solicitors Regulation Authority (SRA) overseen

by a new Legal Services Board. The SRA Board has 17 members, eight solicitors and nine

lay people drawn from a wide range of professions (SRA, 2012) and, unlike the FRC, its

website provides a clear description of who is or is not a lay member.

From 1971 to 2001 the Central Council for Education and Training in Social Work

(CCETSW) was the relevant national body for social workers. In 2001, this was replaced by


two bodies: the General Social Care Council (GSCC) was created as a regulatory body

maintaining a register of staff fit to practice and acting as a disciplinary body; and the

Training Organisation for Social Care (TOPPS) was made responsible for regulating training

and workforce planning. The nine board members of the GSCC include four registered

social workers and five lay members (GSCC, 2012). Subsequent changes to regulators in

the health and social welfare sector abolished the GSCC in 2012 with its functions taken by

the Health Professions Council (HPC) (GSCC, 2012b). The HPC has 18 members, nine lay

and nine from a range of health care professions, such that not all its 15 regulated

professions are represented.

From 1983, the regulation of nurses, midwives and health visitors was the

responsibility of the UK Central Council and by 1992 (1992 Act) it had a Council of 60

members drawn from the profession, either elected or appointed to represent different parts

of the UK and those involved in the education and training of the profession. Professional

dominance ended in 2002 with the Nursing and Midwifery Council established as a new

regulatory body, initially one-third of whom were lay (JM Consulting Ltd, 1998) with later

changes to a smaller Council of 13, seven of whom are lay (NMC, 2012; NMC, 2012a).

With 12 medical members and 12 lay members, the current structure of the General

Medical Council (GMC) also reflects the contemporary emphasis on fewer members and

stronger lay representation (GMC, 2012). This contrasts with a Council of 93 members in

1978, of whom seven were lay and a further change in 2003 when a smaller Council was

established with 40% lay membership (Irvine, 2006). In addition to the structural change in

composition of the GMC, there has also been a substantial extension of its role so that its

traditional regulation of initial medical education has been extended to post graduate medical

education, previously the largely autonomous domain of the several medical Royal Colleges

(Irvine, 2006).

In the context of Friedman’s view that all professions should be de-regulated, it might

be argued that the neo-liberal perspective has gained little traction. However, while belief in

the wider benefits of occupational licensing evidently remains, the changes are consistent

with the second part of our proposition on the influence of the neo-liberal critique: if the right

to undertake certain types of work is to be restricted by licence, then stronger and

independent regulatory oversight is required. The changes to accountants and solicitors

mean all five groups now have a structure of governance that separates monitoring and

representative functions. All five also have a smaller governing body and, excepting

accountants, there is clarity over who are lay members and, moreover, they represent half of

each body; social workers differ only in that their regulatory body oversees several other

health professions. In these respects, neo-liberalism has re-shaped the governance of these

professions. However, as we see in the next section, the nature and extent of the impact on


CPD by regulators is mediated by other factors, including how these groups ‘achieved’ their

professional status.

Professionalism and changing rules for CPD

Perspectives from sociology provide more nuanced perspectives than neo-liberal economics

on the role of professional groups, although scepticism about motive was prominent among

some writers in the 1970s and 1980s with professionals viewed in ways not dissimilar to

neo-liberal economists (Johnson, 1972; Larson, 1977). More common has been the

argument that the work of professionals is distinctive from non-professionals and require

ways of organising work that differ from market and bureaucratic forms, exemplified by

Freidman’s categorization of it as the ‘third logic’ (Freidson, 1994; Freidson, 2001).

Professionals are seen as having attributes that differ from non-professional workers,

leading them to have a different relationship with conventional management hierarchies

(Tobias, 2003; Evetts, 2011). While this has contributed to work on identifying these

attributes, more pertinent for our analysis is how occupational groups ‘achieve’ professional

status, specifically whether the practices associated with professional characteristics are

defined by members of an occupational group (‘professionalism from within’) or defined for

them by an external body (‘professionalism from outside’) (McClelland, 1990). Evetts argues

that groups who define themselves (i.e. ‘from within’, such as law and medicine) have

historically been more successful in promoting their identity and securing regulatory

responsibilities. Where professionalism is defined ‘from outside’, typically in public service

occupations, she argues it is used to promote and facilitate change and as a disciplinary

mechanism but retains an appeal to occupational groups because of ‘the idea of service and

autonomy’ embodied in the concept. In practice, she asserts, the reality of professionalism

‘from outside’ ‘includes the substitution of organizational for professional

values;…managerial controls rather than collegial relations; managerial and organizational

objectives rather than client trust and autonomy based on competencies and expertise;…the

standardization of work practices rather than discretion; and performance targets,

accountability and sometimes increased political controls’(Evetts, 2011, p.13).

That these values, controls and characteristics are now so prominent in the public

sector owes much to the impact of neo-liberal economics. Alongside the competition

created by quasi markets (Le Grand, 2007) these forms of control are used to ‘bend’ state

employees to be more responsive to client and customer interest and are found in

administrative structures and processes known as New Public Management (NPM) (Pollitt

and Bouckaert, 2011). While some see the blurring of management approaches between

the public and private sectors as reason for questioning the usefulness of the distinction

(Evetts, 2011), we share the view of others that the impact of NPM on public sector


professionals is significant (Lapsley, 2009; Leicht, Walter et al., 2009) and merits inclusion in

our comparative framework. Doing so allows us to assess, for example, whether the

discretion of a ‘from within’ professional group predominantly in the public sector (e.g.

medicine) has altered vis-à-vis a group predominantly in the private sector (e.g. solicitors).

More broadly, examining differences in the state’s relationship with public sector and private

sector dominant professions leads to our second proposition:

Applying the aspects of professionalism highlighted here, we might (a) discern

differences in CPD policies that arise whether a professional group is defined ‘from

within’ or ‘from outside’; and (b) whether or not a group is public or private sector

dominant.

CPD rules, requirements and expectations

There are four UK accountants associations, the Institute for Chartered Accountants for

England and Wales (ICAEW), its Scottish partner (ICAS), the Association of Chartered

Accountants (ACCA) and the Chartered Institute of Management Accountants (CIMA) and,

until the 1980s, CPD was an implicit professional obligation rather than a requirement of

membership. Legislation in 1986 and 1989 altered this for auditors and insolvency

practitioners, leading in 2004 to the International Federation of Accountants (IFAC)

effectively making CPD a requirement (Paisey, Paisey et al., 2007). Of the four

associations, only the ACCA specifies time, requiring 40 hours annually, of which 21 must be

verifiable by evidence such as course materials, notes or certificates (ACCA, 2012). Others

suggest possible activities (ICAEW, 2012), guidance on preparing a development

programme and recording activities (ICAS, 2011) and advice on a structured six stage

professional development cycle (CIMA, 2012). While all associations require members to

keep a record of activity which can be requested for audit, they leave much to individual

discretion and the FPC as regulator has no discernible policy on CPD.

For solicitors, regulations since 1990 require one hour of CPD for each month in

practice in a year, rising to 16 hours annually from 2001 (SRA, 1990), and this remains the

requirement (SRA, 2010). At least 25% of this time must be met by participation in

accredited courses and detailed examples of other acceptable activities emphasise more

formal CPD with less formal, such as mentoring or shadowing, allowed but requiring

documentation and sometimes accreditation (SRA, 2010). Solicitors are required to

maintain a record and keep it for at least six years (SRA, 2007). However, the creation of

the SRA as an independent regulator has triggered a major review, engaging the profession

(LETR, 2012), commissioning research reports and examining practice in other professions

(SRA, 2011b). Working documents indicate more emphasis on CPD becoming part of a


wider system of Outcomes Focussed Regulation (OFR) where responsibility for CPD

outcomes is an obligation both for individual solicitors and the ‘entities’ in which they work

(SRA, 2011a; SRA, 2011b; SRA, 2011c). There is also discussion whether entities may be

required to provide CPD within designated ‘themes’ (ethical behaviour is an example) to

ensure they are meeting their obligations to customers. As there is also discussion on

whether guidelines should be provided on integrating CPD learning outcomes within staff

appraisal and performance management systems (SRA, 2011a), there is potentially

profound change arising from this new regulator.

Following recommendations in the Climbié inquiry in 2003, social workers in 2005

were required for the first time to undertake a minimum of 90 hours of CPD (or 15 days over

three years) of study ‘which could reasonably be expected to advance the social worker's

professional development or contribute to the development of the profession as a whole’

(GSCC, 2012a). Following the Baby ‘P’ case, this system was described as ‘loosely defined

and not rigorously monitored’ and it was recommended CPD be linked to more demanding

re-registration, including ‘clear evidence of how the learning undertaken has led to

improvements in practice’ (SWTF, 2009). These proposals are being taken forward (SWRB,

2010) by a new College of Social Work which will begin endorsing providers who ‘can

demonstrate the relevance of their learning criteria for social workers’ (CoSW, 2012). The

swiftness of these changes indicate an approach more dirigiste than for solicitors and,

despite aligning its CPD policy with the regulator’s, attempts by the British Association of

Social Workers (BASW) to become a partner in the College were re-buffed (BASW, 2012a;

BASW, 2012b).

CPD became compulsory for nurses, midwives and health visitors in 1995 in

requirements set out by their regulator (UKCC, 1994). A minimum of five days or 35 hours

of CPD was required over a period of three years to maintain registration with activities

expected to be informed by the regulator’s code of conduct (NMC, 2008). The initial

arrangement of self-validation assumed registrants would undertake study relevant to their

branch of nursing (Glovier, 1999) but from April 2000 all nurses and midwives must declare

they have met the minimum requirement, maintain a professional portfolio and, if required,

make this available for audit (NMC, 2011). For those working in the NHS, the portfolio is

used as evidence within the employers’ appraisal system and, in that sense, is part of the

performance management system.

As with accountants, CPD for doctors was initially viewed as an implicit obligation. It

arises contractually in 1990 when a new contract for GPs included an allowance they could

reclaim against the cost of up to 30 hours CPD annually if undertaken (Murray and

Campbell, 1997). Even today, practice varies between the medical royal colleges so that, for

example, since 2002, the Royal College of Physicians (RCP) has required members to make


an annual return showing a minimum of 50 CPD hours/credits while this amount is advisory

for GPs (RCGP, 2008). However, the imminent integration of CPD with appraisal and

revalidation make these differences less significant.

Commenting on the impact of the inquiries and reports into Bristol, Alder Hey, etc.,

Douglas Irvine (Chairman of the GMC at the time) wrote, ‘The profession went into a state of

shock. Public opinion demanded action’ (Irvine, 2006). Unlike the changes swiftly imposed

on social workers after the Climbié and Baby ‘P’ inquiries, however, changes in the

accountability and CPD of doctors have been at a more measured pace.

In 1999, the Department of Health welcomed the profession’s proposals on

revalidation of doctors’ right to practice (DH, 1999) and it was discussed even earlier by the

GMC and royal colleges (Irvine, 1997a; Irvine, 1997b; Lawson, 2012). A substantive change

occurs in 2002 when peer based formative appraisal became a requirement and CPD a

component of the review (DH, 2002), which is when the RCP introduced a required minimum

of 50 hours/credits of approved CPD annually. Thirteen years later, however, revalidation

has not been implemented, despite many suggestions of its imminence (Southgate and

Pringle, 1999; McKinley, Fraser et al., 2001; Ellis, 2004). Now set for introduction in late

2012, the likely final scheme integrates appraisal and revalidation, with CPD one component

of an extensive range of information that includes feedback from colleagues and patients

(GMC, 2012a; GMC, 2012e; GMC, 2012f; GMC, 2012g; GMC, 2012h). The scheme also

differs from the other professions as the CPD undertaken by doctors has to be mapped

against the regulator’s statement of what constitutes good medical practice (GMC, 2009)

and will also underpin revalidation.

Despite both groups suffering from a decline in public confidence, the time taken to

secure revalidation for doctors with its implications for CPD contrasts with how rapidly CPD

was introduced and then altered again for social workers. We suggest three sets of reasons

why the process has extended over several years. First, is the difficulty of devising a system

that integrates the requirements of revalidation with the formative aspects of appraisal and

NHS management requirements of clinical governance (Shaw, MacKillop et al., 2007) whilst

also reconciling the sometime competing interests on so many stakeholders, including the

Department of Health, NHS management, the GMC itself, the Royal Colleges and the BMA

(Salter, 2007). Second, is a demand from within the profession for a system that meets

acceptable statistical standards of validity and reliability with studies testing components of

likely schemes (UKCEA, 2007; Bruce, 2004); Campbell, 2011; Conlon, 2003; Southgate,

1999), although these have not prevented the introduction of revalidation in the USA and the

Netherlands with substantial progress elsewhere (Peck, McCall et al., 2000; GMC, 2010).

This leads to a third set of reasons for slow progress, which may be a professional

reluctance to a change that increases scrutiny of individual doctors. The complexity of the


doctors’ role undoubtedly provides reason for proceeding carefully but some have

questioned whether the difficulties have loomed too large, leading the Health Select

Committee to express concern at the limited attention given to how to deal with doctors

whose practice gives cause for concern and whether sight is being lost of the purpose of

protecting patients (HC, 2011).

How do these changes relate to identities as ‘within/outside’ professions? The

weakness of social workers is evident, losing its own regulator to oversight by the HPC, the

swift imposition of CPD requirements and their subsequent tightening, all markedly different

from solicitors and doctors. Although both of these are undergoing substantial change in

arrangements related to their CPD, the process is more extended and negotiated; self-

regulation for them is not what it was but each profession is fully engaged in discussions on

change. Of nursing, what emerges from their recent history is less imposed than social

workers but less negotiated than solicitors and doctors and, like social workers, through

appraisal, CPD is integrated into a hierarchic management structure. With light touch

regulation and minimal rules in relation to CPD, accountants fit the ‘within’ category.

Dominance as a private or public sector profession does not appear significant, however,

with developments for solicitors closer to doctors than accountants. Any temptation to view

this as an effect of being part of a financial sector with a recent history of minimal regulation

must be balanced by the evidential limits of our small number of cases.

4. EFFICIENCY AND EQUITY We interpret the concept of efficiency broadly, to include participation rates, modes of

learning and who participates. The empirical data we report on these are interpreted inter

alia with complementary theories drawn from professional learning and the economics of

education. The data also enable us to comment on aspects of equity.

Participation in training

There are three work-related training questions in the QLFS which allow us to identify

participation in training during the previous 13, 4 and 1 week(s). Table 2 shows these rates

in three time phases.


Table 2: Incidence of training Training Accountants Solicitors Social workers Nurses Doctors 13 weeks Phase 1 (1995-2000) 48.5 56.1 58.1 57.9 61.4 Phase 2 (2001-2005) 45.4 60.6 66.4 66.6 68.6 Phase 3 (2006-2010) 40.7 50.7 61.8 59.2 60.6 4 weeks Phase 1 28.4 32.0 32.1 32.8 39.7 Phase 2 24.0 31.4 36.8 37.2 44.1 Phase 3 21.1 25.7 35.2 31.7 38.0 1 week Phase 1 12.9 13.9 13.8 16.7 23.3 Phase 2 10.6 12.5 16.6 19.0 24.4 Phase 3 10.2 11.3 17.6 15.5 22.2 Source: QLFS, 1995-2010.

Accountants report the lowest level of participation in all weeks and phases, possibly

consistent with the profession’s absence of time targets; their levels of participation also

decline over time. Doctors report the highest overall levels of participation, except in one cell

(13 weeks, Phase 3). Nurses and social workers are next highest with solicitors reporting

similar rates in all Phase 1 weeks but a wider gap in Phases 2 and 3. The higher level of

training in the public sector dominant groups is consistent with other studies (Arulampalam,

Booth et al., 2004; O'Mahony, 2012).

There is an overall decline in participation between Phases 2 and 3, a finding

showing some consistency with an overall decline in the 2000s in the wider workforce

(Mason and Bishop, 2010). Social workers differ, however, with a smaller fall than others

between Phases 2 and 3 and a small increase in week 1 participation, a difference that may

reflect the increased CPD requirement demanded of them after 2005. A decline in training

coterminous with the economic recession raises concerns about maintaining skills levels and

whether the amount of CPD is sufficient for the efficiency of this workforce.

Modes of learning

The extent of flexibility over modes of learning differs quite considerably. Guidance for

accountants is broad and includes informal learning at work (ICAEW, 2012) and for doctors

‘includes both formal and informal learning’, and that ‘not all CPD opportunities will be

planned’ (GMC, 2012c). While current guidance for social workers includes ‘reading books

and articles’ and ‘team meetings which may provide specific learning and development’

(GSCC, 2012c), this flexibility may be reduced by recommendations for more approved

providers after the Baby ‘P’ case (SWTF, 2009). Nurses offer no definition of learning

activities but signal the more formal in the comment ‘you may find it helpful to routinely


collect documentation from any learning activity you undertake, such as appraisals,

attendance or completion certificates’ (NMC, 2011). Where less formal activities are

illustrated for solicitors, as in coaching and mentoring, it is stressed that they are ‘structured

sessions’ with documented outcomes (SRA, 2010). We consider how these policies

correspond to empirical evidence on learner preferences and theoretical perspectives on

learning.

Reporting on early career learning, Eraut identifies learning occurring both as a by-

product of work (e.g. tackling a challenging task) and from activities where learning is the

goal (e.g. shadowing), also noting that activities may be common to both (e.g. asking

questions) (Eraut, 2007). Others distinguish these as formal and informal learning, defining

the former as situations ‘deliberately generated for the purpose of learning’ and the latter as

‘not explicitly set up or organized for learning purposes (Gruber, Harteis et al., 2008).

Whatever classification we use, learning as a by-product accounted for a high proportion of

reported learning among young professionals (Eraut, Alderton et al., 2002; Eraut and Hirsch,

2007) and German data on workers’ perceptions of means of learning, ranked ‘self-learning

in the workplace and experiences from former workplaces’ as the most important, followed

by ‘instructions by and learning from colleagues and supervisors at the workplace’ with

‘Formal further training provided in the firm or by outside suppliers’ at third place (Kuwan,

Thebis et al., 2003). These data on the extent and value of informal learning indicate that

professional associations should interpret their CPD requirements broadly.

Diversity in accepting ‘what counts’ as CPD coheres with diversity of theoretical

perspectives. For theorists such as Sfard, diversity is wholly appropriate as it includes

learning as ‘acquisition’ and ‘participation’, metaphors where acquisition is akin to ‘gaining

possession over some commodity’ and associated with a body of knowledge, and

participation is akin to a process of “knowing” through ‘the constant flux of doing’ and ‘never

considered separately from the context within which they take place’ (Sfard, 1998). This is

consistent with other analyses (McDermott, 1997; Guile and Young, 2002) which argue that

it is as much a misconception that huge amounts of academic knowledge (alone) lead to skill

formation as it is to suggest that huge amounts of practical knowledge (alone) lead to skill

formation (Gruber, Harteis et al., 2008). These contrast strongly, however, with the work of

Lave and Wenger, for whom ‘there is no activity that is not situated’ (Lave and Wenger,

1991), a view of ‘knowing’ as situated and socially constructed which diminishes formal

learning because of its disengagement from the context of application. All the more reason,

the empiricist might argue, why professions should have breadth in ‘what counts’. This also

needs to include learning in groups, crucial for the theorists who - from differing perspectives

- view groups as the appropriate units for analysing learning (Engeström, 2000; Nonaka,

Toyama et al., 2000; Virkkunen and Kuutti, 2000; Engestrom, 2001; Paavola, Lipponen et


al., 2004; Engeström, 2007). The place of collaboration and social relationships in learning

is also consistent with the earlier evidence on worker preferences and segues with studies

showing how training experiences and on-the-job learning are strongly associated with the

nature and level of employee involvement in these decisions (Felstead, Fuller et al., 2005;

Felstead, Gallie et al., 2010).

In enabling diversity, accountants, doctors and, currently, social workers are closer to

learner preferences and the range of theoretical perspectives we have cited; nurses and

solicitors stress the formal. Before concluding that flexibility and diversity is necessarily

better, however, we consider the risk of excessive autonomy? At a time when the growth of

professional knowledge and its electronic access creates problems in defining bodies of

knowledge, a study of young professionals leads Jensen to reflect on their difficulties in

managing their learning so that it is relevant and time-efficient, concluding that without their

controlling bodies providing ‘a stronger emphasis on navigational aids and epistemic

structures our results suggest that the professions (sic) may develop into ambitious but

aimless learners’ (Jensen, 2007). It is a challenge that may extend beyond young

professionals. In providing a framework of what constitutes good medical practice,

therefore, might the GMC be right in providing flexibility over means but a clearer structure

over content in a statement on knowledge and skills, safety, communication and teamwork,

and trust (GMC, 2012d).

Human capital accumulation

Learning in work contributes to productivity, and even when measured in terms of formal

activities only recent work suggests it accounts for one-fifth of the contribution of ‘knowledge

inputs’ to economic growth (O'Mahony, 2012). Becker’s Human Capital Theory provides the

principal economic theory on the economic returns to learning at school and in work (Becker,

1964). Its extensive international evidence base continues to grow and shows clear

evidence that the more highly educated and highly skilled are the main recipients of

expenditure (Jenkins, Vignoles et al., 2002; Arulampalam, Booth et al., 2004; Dolton,

Makepeace et al., 2005; Macleod and Lambe, 2008), a finding consistent with predictions,

whereby changing technological conditions require more training and this is more likely to be

given to the more highly skilled because they provide a higher return (Blundell, Dearden et

al., 1999; Vignoles, Galindo-Rueda et al., 2004). Also consistent with the theory is that

younger workers are more likely beneficiaries because there is a longer period of return on

the investment (Oosterbeek, 1998; O’Connell and Jungblut, 2008), although this effect may

increasingly be influenced by more rapid skills obsolescence (Arulampalam, Booth et al.,

2004). Evidence on the effect of part time workers is mixed and, unlike several other


European countries, those in the UK are less likely to be trained (Arulampalam, Booth et al.,

2004).

The theory does not address non-market conditions and, therefore, makes no

predictions about the public sector, although the evidence is that public sector workers are

more likely to receive training (Arulampalam, Booth et al., 2004; O'Mahony, 2012). Possible

explanations may be the different composition of the workforce in the sector or the more

limited influence of cost pressures compared with the private sector. Economies of scale

also suggest larger organizations spend more on training.

Other quasi-organizational factors included are whether accountants, solicitors and

doctors are self-employed or not because 98% of social workers and 99% of nurses were

employees; for these two groups we include two dummy variables, whether they have a

management role or a permanent job. In addition, we include equity related factors such as

gender and ethnicity which, although not in the conventional model, allows us to examine - in

the next section - their effects on access to training. Year dummies are also included to

examine their effects on levels of training participation.

We estimate separate Probit models for the five professions with training in the 13

weeks as the dependent variable and controlling for individual and organisational

characteristicsii. Table 3a and 3b report the estimated coefficients.


Table 3a: Determinants of training ED13WK Accountants Solicitors Soc

W k Nurses Doctors

Age 30-39 -0.473*** -0.309*** -0.017 -0.044 -0.068 (-6.82) (-3.54) (-0.18) (-1.13) (-0.86) 40-49 -0.684*** -0.366*** -0.1 -0.073* -0.266*** (-8.23) (-3.55) (-0.98) (-1.70) (-2.96) 50-59 -0.723*** -0.416*** -0.224** -

-0.360***

(-7.56) (-3.50) (-2.02) (-4.06) (-3.60) 60-69 -0.952*** -0.587*** -0.554*** -

-0.559***

(-6.75) (-3.44) (-3.40) (-6.93) (-4.36) Education Higher education 0.025 -0.063 0.059 -0.055* -0.362*** (0.28) (-0.20) (0.89) (-1.85) (-3.48) GCE A & GCSE A-C -0.024 0.134 -0.069 0.045 -0.411** (-0.43) (0.99) (-1.07) (0.84) (-2.36) Other qualification -0.486*** -0.178 -0.048 -0.166** 0.042 (-3.90) (-1.00) (-0.45) (-2.48) (0.46) No qualification -0.738** -0.093 -0.552*** -

-0.739

(-2.28) (-0.15) (-2.99) (-2.59) (-0.99) No. of employees 1-10 -0.057 -0.153 -0.068 0.036 -0.184** (-0.72) (-1.61) (-0.70) (0.76) (-1.96) 11-24 -0.068 -0.148 -0.083 0.098** -0.01 (-0.86) (-1.62) (-0.94) (2.50) (-0.14) 25-49 0.058 -0.131 0.124 0.094** 0.137 (0.70) (-1.37) (1.30) (2.47) (1.55) 50-499 -0.162*** -0.074 -0.108 -0.019 -0.136** (-2.63) (-0.96) (-1.26) (-0.67) (-2.14) Full time 0.221** -0.034 0.180*** 0.056** 0.02 (2.29) (-0.35) (2.78) (2.16) (0.29) Private -0.307*** -0.093 -0.096 -

-0.059

(-4.46) (-1.08) (-1.31) (-7.32) (-0.64) Time with current

1 year but <2 -0.111 -0.013 0.059 0.122** -0.116 (-1.26) (-0.13) (0.55) (2.44) (-1.37) 2 years but <5 0.018 -0.006 -0.033 0.016 -0.067 (0.24) (-0.07) (-0.36) (0.38) (-0.93) 5 years but <10 -0.101 -0.122 -0.152 -0.063 0.001 (-1.27) (-1.26) (-1.60) (-1.48) (0.01) 10 years but <20 0.025 -0.087 -0.096 -0.068 -0.03 (0.31) (-0.86) (-0.99) (-1.61) (-0.37) 20 years or more -0.135 -0.124 -0.045 -

0.036

(-1.37) (-1.00) (-0.38) (-2.78) (0.37) Employee -0.500*** -0.092 - - -0.264** (-6.71) (-1.30) (-2.47) Manager - - 0.148*** 0.206*** - (2.70) (8.69) Permanent - - 0.275** 0.03 - (2.54) (0.56) Log likelihood -2228.7 -1662.9 -1788.2 -9151.3 -2511.5 N 3436 2545 2802 14167 3993

Notes: Table 3a and 3b are part of the same Probit regressions but presented in two parts to correspond with our arguments. z statistics in parentheses, *** Significant at 1%; **Significant at 5%; * Significant at 10%. All Probit regressions include a constant and year dummies. Reference categories: aged 16-29, degree level, number of employees 500 or more and working in the current job (or with current employer) less than 1 year.


Despite the inevitable skewing of qualifications towards higher levels of education,

resulting in small numbers with lower level qualifications, the results are consistent with

theory, most clearly for accountants and nurses. With respondents with degrees as the

comparator group, accountants with ‘other’ and ‘no qualifications’ are less likely to have

training and similar but less marked results is found for nurses. The 2% of social workers

with no qualifications are also less likely to report training. Doctors with sub-degree higher

education and GCE A/GCSE A-C are less likely to report training but the data requires

clarification: those qualifying overseas are always classified as ‘other’ and we assume other

cases are reporting or coding errors. We find no significant impact of education on training

for solicitors.

Consistent with the theory and the literature, our results show an age effect on the

probability of job-related training with people generally less likely to engage in training as

they get older. There is a clear declining trend for accountants and solicitors with the

magnitude of the coefficients smaller for doctors. For social workers and nurses, the

significant age effect is only for those aged 50 and above and is more noticeable for those

aged 60-69.

Full time working has a positive relationship with participation among accountants,

social workers and nurses, consistent with other data on the UK workforce. That this is not

the case for solicitors may reflect the profession’s relatively low level of reported CPD but

does not explain the finding for doctors. Years with employer shows almost no effect, a

result not consistent with the theory. A significant relationship occurs only for nurses:

compared to the reference group of those working less than 1 year, nurses with their current

employer ‘1 year but less than 2’ are more likely to have training while those with an

employer for ‘20 years or more’ are less likely to be trained, a finding consistent with theory

and other studies.

Comparison of training participation shows accountants and nurses working in the

private sector are much less likely to participate in training but this difference does not occur

with the other three professions. Meriting further inquiry, therefore, is whether professions

‘formulate training expectations’ and how influential they are in influencing levels of training,

irrespective of the sector in which someone is working. Notwithstanding this, public sector

dominant groups, including doctors, are more likely to participate in training in all three time

phases in Table 2. Consistent with other studies, it raises questions whether the differences

reflect: under/over investment, different workforce needs; government policies; or some

combination of these. For example, with some success, the Department of Health gave

greater priority to training in the early 2000s (Thomas and Qiu, 2012) and we have seen that

greater CPD requirements were imposed on social workers.


While the wider literature shows large firms typically offering more training, these

data show limited effects with none shown for solicitors and social workers. Among

accountants, when compared with the reference group of workplaces with 500 or more

employees, those in workplaces sized 50-499 are less like to have training in the last 13

weeks and there is a similar negative relationship for doctors, as well as for those in

workplaces with 1-10 employees. Among nurses, 51% of whom were at workplaces with 500

or more employees, those in smaller workplaces of 11-49 are more likely to have training.

Whether respondents were employees (against self-employed) was included in the

regression only for private-sector dominant professions and for doctors. Our results show a

significant negative impact of this variable on training for accountants and doctors; that is,

self-employed accountants and doctors (largely GPs) are more likely to access training. For

the two public-sector dominant professions, social workers with a permanent job and a

managerial role are more likely to have job-related training, which is also the case for nurses

in management roles.

Although not reported in the Table, with 1995-2000 as the comparator period all

groups except accountants were more likely to access training in 2000-2005, a period before

the impact of the financial crisis starting in 2007. For social workers, the third period, 2005-

2010, also shows increased participation compared with 1995-2000, a result consistent with

the timing of changes in CPD requirements for social workers. This confirms the descriptive

data in Table 2.

In summary, the human capital analysis suggests that, in terms of who participates,

the results are broadly consistent with the theory’s predictions. The absence of

‘benchmarks’ as to what constitutes an optimum level of training, however, make it difficult to

assess whether there is an appropriate overall level of training. However, private sector

changes that, in some degree, reflect overall economic activity suggest that cost constraints

may be influencing factors on investment in training while government policy may be

influencing participation in the public sector dominant groups.

Equity and access to training

Evidence on gender and access to training is mixed. There is evidence that women are

more ready to pay for their training (Bassanini, Booth et al., 2005) with more recent EU wide

data showing females more likely to receive training than males but for less time (O'Mahony,

2012). We also include factors for ethnicity, marital status and dependent children.


Table 3b: Determinants of training ED13WK Accountants Solicitors Soc

workers Nurses Doctors

Men -0.04 -0.158** -0.068 -0.012 -0.117** (-0.71) (-2.55) (-1.11) (-0.28) (-2.35) Ethnic background White 0.125 0.228 -0.328* 0.07 -0.017 (0.84) (1.17) (-1.75) (1.13) (-0.20) Asian (British) 0.018 -0.275 -0.351 0.003 -0.12 (0.10) (-1.22) (-1.54) (0.04) (-1.30) Black (British) 0.201 0.645** -0.322 0.107 -0.009 (0.88) (2.06) (-1.52) (1.36) (-0.06) Marital status Single 0.05 0.09 -0.132** 0.03 0.123* (0.78) (1.22) (-1.97) (0.92) (1.79) Divorced 0.077 0.022 0.08 0.073* -0.1 (0.71) (0.17) (1.02) (1.89) (-0.85) Other 0.109 0.098 0.349*** 0.033 0.017 (0.73) (0.58) (2.90) (0.67) (0.12) Dependent children

-0.15 -0.102 -0.241 -0.246** -0.052

(-1.46) (-0.90) (-1.46) (-2.23) (-0.63) Women*dependent

-0.441*** -0.468*** -0.400** -0.330*** -0.237*

under 2 (-2.78) (-2.92) (-2.02) (-2.83) (-1.88) Dependent children 0.001 -0.073 0.054 -0.074** -0.076 aged 2-4 (0.01) (-0.90) (0.55) (-2.03) (-1.18) Dependent children -0.067 0.053 0.015 0.01 0.053 aged 5-9 (-1.00) (0.69) (0.21) (0.34) (0.94) Dependent children 0.129* -0.001 0.072 0.079*** 0.035 aged 10-15 (1.91) (-0.02) (1.08) (2.75) (0.58) N 3436 2545 2802 14167 3993

Notes: z statistics in parentheses, *** Significant at 1%; **Significant at 5%; * Significant at 10%. Reference categories: other ethnic backgrounds and married.

On gender, women solicitors and doctors are more likely to participate in training in

last 13 weeks. Having dependent children under 2, however, is one of the most significant

determinants of less training for all five professions, although the magnitude of the coefficient

is smaller for doctors and, for nurses, this negative relationship is also found for those having

dependent children aged 2-4, although those with dependent children aged 10-15 are more

likely to have training. Unsurprisingly, this negative effect of having dependent children

under 2 years has a strong interaction with gender with women most affected, after we

introduce the interactive term of women*dependent children under 2, a result that may

influence subsequent career progress. In other words, this negative relationship is only for

women, except for nurses with both variables significant, indicating the strengthened impact

for women. A significant relationship between marital status and job-related training occurs

for social workers in that those who are single less likely to have training compared with

those who are married or have ‘other marital status’.

The impact of ethnic background on training participation is limited to Black (British)

solicitors, who are more likely to have undertaken training compared with other ethnic


backgrounds. While this suggests ethnicity may not influence access to training once

someone has a place in a profession, we are clear these data tell us little about initial access

to these professions and it is certainly the case that there is continuing concern about

patterns of recruitment into professions such as law and medicine (Boon, 2005; Sommerlad,

2007; Sommerlad, 2008).

The age effect we identified earlier may also be an equity issue in an economy

expecting people to work longer. As it is not clear from these data whether lower levels of

training by older workers or part time workers are decisions by employer or employees, they

are areas requiring further enquiry.

5. CONCLUSION The neo-liberalism of the last three decades has re-shaped the accountabilities of these five

professions with oversight by stronger regulatory boards and, excepting accountants, clarity

as to the identity of lay members who now have equal representation. While the status

distinction between professions defined ‘within’ and ‘outside’ is relevant in understanding

change, they are also mediated by other factors, which include public concern about some

professions, the activism of a regulator and, possibly, alignment with the financial sector.

With respect to professional autonomy over CPD, the NPM surrogate of neo-liberalism is

evident: there is a clear shift towards a closer integration of CPD with performance

management for nurses and social workers and is an option under consideration for

solicitors; it is less clear how five-year re-validation for doctors might develop as a form of

performance management. Evidence on who participates in CPD is largely consistent with

human capital theory predictions on efficiency but, in terms of the incidence of participation,

activity owes much to wider economic conditions, although the slower decline of participation

among social workers may reflect their new CPD rules. An apparent greater emphasis on

formal learning for nurses, social workers and solicitors run counter to empirical evidence

and theoretical perspectives which emphasise the effectiveness of diversity in modes of

professional learning. On the equity criterion, older workers, part-time workers and women

with young dependents have lower levels of participation.

These findings lead to questions on the future nature of CPD and, more broadly,

learning at work. The greater integration of CPD with appraisal, more demanding

requirements for maintaining registration and periodic revalidation places a greater onus on

individual performance and, depending on how the CPD requirements of each profession

are defined, may influence attitudes to learning in teams. Questions about the content of

CPD are raised by the GMC’s requirement that doctors use Good Medical Practice (GMC,

2009) as a framework for guiding their CPD: as professional knowledge and the ease of its


electronic access grow, is providing a structure of what constitutes good practice an

approach other professions should consider? This leads to a more general question as to

whether these new or newly constituted regulators will also be newly energised: will the

activism shown by the SRA in its current review of CPD for solicitors become a stimulus to

others? If so, we cannot be clear at this stage what direction this may take, but we note one

development. In its review, the SRA has selected ethics as a CPD theme to examine;

meanwhile, the GMC has highlighted probity in its guidance on revalidation. Does this

attention to ethics, probity and what constitutes good practice represent a fresh emphasis on

conceptions of the duties of a professional who, while depending on their work for their

income ‘do not consider that any conduct which increases their income is on that account

right’ (Tawney, 1952, p.108)? Might a paradox of the market morality of neo-liberalism that

has re-shaped professional regulation be CPD activities that reinforce the values of

professionalism?


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i The data are skewed for gross weekly pay, so the means are calculated by taking the log of this variable, and antilog afterwards. ii The detailed profile of these factors included in our model is available from the authors on request, as well as the full Probit regression results for Table 3a and 3b.

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