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a blog by Chris Barrow

The Commoditisation of Professionalism

History Collage

A recent Facebook post that shared a recruitment advert from a micro-corporate, looking for young qualified dentists to join as salaried apprentices, generated a significant thread of comments.

Those who took the trouble to express their views were equally divided between:

  1. good idea – a great way to start a career pathway (especially with the clinical and personal development support included in the package);

  2. bad idea – OMG, how remuneration has fallen since I graduated – how can you expect people to work for less money when they carry student loans? What’s the catch? Who is getting rich at the young dentists’ expense? I’d rather be a supermarket manager than work in those conditions.

The enthusiasm of all the commentators led me to ponder on the issue over the last week and question exactly what we are witnessing here.

My mind was drawn to the rise and fall of the medieval craft and merchant guilds originally introduced to Europe around the time of the Norman Conquest, achieving prominence in the 14th Century.

In England today there are still over 110 guilds (now known as livery companies) still in existence but only for ceremonial purposes as their power to influence the macro-economy has long since vanished.

In their heyday, they competed with the landed aristocracy for supremacy from the time of the English Civil War (and the rise of Puritanism) and, in spite of the reinstatement of the monarchy after Cromwell, their power inexorably grew through and into the 18th century and the establishment of our current line of royalty from their Hanoverian ancestors.

The aristocracy faded and was replaced by the craft, merchant and professional classes – a scenario repeated in France during and after their own Revolution and the ensuing Napoleonic era but resisted in Russia, Austria-Hungary, Spain and other fragmented European monarchies, where increasingly detached royalty clung to power until the 20th Century and the years of mechanised revolution and war.

Kings and Queens came and went – but the craft, merchant and professional classes morphed into modern-day capitalism, making money in times of peace and conflict through their specialisations.

“The guild tended to be an extremely hierarchical body structured on the basis of the apprenticeship system. In this structure, the members of a guild were divided into a hierarchy of masters, journeymen, and apprentices. The master was an established craftsman of recognised abilities who took on apprentices; these were boys in late childhood or adolescence who boarded with the master’s family and were trained by him in the elements of his trade. The apprentices were provided with food, clothing, shelter, and an education by the master, and in return they worked for him without payment. After completing a fixed term of service of from five to nine years, an apprentice became a journeyman, i.e., a craftsman who could work for one or another master and was paid with wages for his labour. A journeyman who could provide proof of his technical competence (the “masterpiece”) might rise in the guild to the status of a master, whereupon he could set up his own workshop and hire and train apprentices. The masters in any particular craft guild tended to be a select inner circle who possessed not only technical competence but also proof of their wealth and social position.” (Encyclopaedia Brittanica)

The 21st Century Healthcare Professional

In 2013, American surgeon Dr. Jeffrey Singer published an article entitled “How Government Killed the Medical Profession”

A stunning read that I would recommend to any dentist who wants to understand what we can learn from the commoditisation of USA healthcare as a clue to the present and possible future of UK dentistry.

For the busy, I urge you to bookmark the article and return when you have the time – worth the effort.

For now, Singer references:

  1. The Coding Revolution – targets and codes for treatment that seem hauntingly similar to the UDA system

  2. Command and Control – the imposition of protocols to override discretion and experience

  3. Electronic Records and Financial Burdens – compulsory digitisation, the dominance of insurers and price controls

  4. Accountable Care Organisations – the allocation of patients to accredited healthcare firms

  5. Doctors going Galt – doctors turning into assembly-line workers

  6. Medicine in the Future – the rise of “cash-only personalised private care”

I quote from Dr. Singer’s final paragraphs:

Ayn Rand’s philosophical novel Atlas Shrugged describes a dystopian near-future America. One of its characters is Dr. Thomas Hendricks, a prominent and innovative neurosurgeon who one day just disappears. He could no longer be a part of a medical system that denied him autonomy and dignity. Dr. Hendricks’ warning deserves repeating:“Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn’t.”

Dr. Singer bemoans these developments and announces his own impending departure from the medical profession.

Here in British dentistry, we have rehearsed over and over again:

  1. The history of the NHS dental contract

  2. The rise of dental corporates

  3. The rise of retailers, supermarkets and health insurers

  4. The rise of goodwill values

  5. The rise of the private dental market

  6. The arrival of branding, marketing, customer service and digitisation into a profession that, just 20 years ago, was the epitome of the traditional middle-class professional guild

  7. And now – it appears – the commoditisation of professionals into apprentices and journeymen before they can describe themselves as masters – and the decline of their influence as a guild

Both Adam Smith in his “Wealth of Nations” and Karl Marx in “The Communist Manifesto” heralded the decline of the pseudo-monopoly enjoyed by guilds – a decline that progressed through the 18th and 19th centuries.

Some evolved into trades unions and others into “worshipful companies” – each would have their own temporary or limited influence on the economic stage,

DeclineIn their heyday from the 12th to the 15th century, the medieval merchant and craft guilds gave their cities and towns good government and stable economic bases and supported charities and built schools, roads, and churches. Guilds helped build up the economic organisation of Europe, enlarging the base of traders, craftsmen, merchants, artisans, and bankers that Europe needed to make the transition from feudalism to embryonic capitalism. They were frequently hostile to technological innovations that threatened their members’ interests, and they sometimes sought to extinguish commercial activities that they were not able to bring under their own control.Merchants were becoming capitalistic entrepreneurs and forming companies, thus making the merchant guilds less important. Craft guilds broke down as the pace of technological innovation spread and new opportunities for trade disrupted their hold over a particular industry. Masters tended to become foremen or entrepreneurs, while journeymen and apprentices became labourers paid their wages by the day. The emergence of regulated companies and other associations of wealthy merchant-capitalists thus left the guilds increasingly isolated from the main currents of economic power. (Encyclopaedia Brittanica)

The 20th Century saw the emergence of the corporation as the primary power-centre in economics. Big business, big politics and big military were the decision-makers.

We now witness a shift, about which I intend to write further in the future – the emergence of the digital super-powers to replace the cultural and economic super-powers of the last 100 years.

The rise of big data.

Goodbye The USA, The Soviet Union and China as super-powers.

Is it now really about BRICS (Brazil, Russia, India, China and South Africa)?

Or is it AFGA?

  1. Apple

  2. Facebook

  3. Google

  4. Amazon

AFGA have infiltrated every aspect of our lives without reference to political, religious, ethnic or geographic boundaries.

Those who live in communities where these digital superpowers are absent or prohibited are becoming the inhabitants of a New Dark Age.

Today’s digital guild is a MMOG (massive multi-player online game) – look at Pokemon Go.

In the meantime, the privileged position of the healthcare professional is being eroded by global and national forces for change.

Change that impacts at the grass roots level – when we discuss the “going rate” for a 35-year old qualified dentist offered a basic salary of £35,000 for a 5-day week in a Derbyshire micro-corporate.

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