Charismatic authority in modern healthcare: the case of the ‘diabetes specialist podiatrist’
Address for correspondence: Alan M. Borthwick, Centre for Innovation and Leadership in Health Sciences, Faculty of Health Sciences, University of Southampton, Building 45, Highfield, Southampton S017 1BJ
Professional specialisation is broadly considered to result from increased complexity in professional knowledge and to be linked to specialist education, formalised credentials and registration. However, the degree of formal organisation may vary across professions. In healthcare, although medical specialisation is linked to rigorous selection criteria, formal training programmes and specialist registration, some forms of specialisation in the allied health professions are much less formal. Drawing on Weber’s concept of charismatic authority, the establishment of a specialist role in podiatry, the ‘diabetes specialist podiatrist’, in the absence of codified or credentialed authority, is explored. ‘Charismatic’ leaders in podiatry, having attracted a following of practitioners, were able to constitute a speciality area of practice in the absence of established career pathways and acquire a degree of legitimacy in the medical field of diabetology.
In the health division of labour, considerable sociological attention has been paid to the way in which professions seek to establish, maintain and extend their boundaries, as part of a broader ‘professional project’ (Freidson 1970, Larkin 1983, Larson 1977, MacDonald 1995, Willis 1983, 2006). In recent years, healthcare modernisation has challenged traditional workforce boundaries and workforce flexibility has been encouraged (Nancarrow and Borthwick 2005). Indeed, over the last two decades the contribution of the allied health professions (AHPs) has been viewed as an important policy focus in addressing the need for workforce flexibility and service redesign (Department of Health 2000a, 2000b, 2008a), enabling and encouraging role transfer and extended scope practices, particularly in task domains previously exclusive to medicine (Boyce 2008, McPherson et al. 2006). In an increasingly complex healthcare workforce, modernisation, characterised by enhanced accountability, governance, patients’ choice and a new professionalism marked by more fluid role boundaries, has resulted in greater potential for role change and development (Green et al. 2011, Kuhlmann 2006, Martin et al. 2009, Sanders and Harrison 2008).
Specialisation has been viewed as one of a number of possible ways in which the healthcare workforce may be reshaped and redesigned (Nancarrow and Borthwick 2005). It involves claims to higher levels of skill within a specific disciplinary field and is usually identified with membership of a closed subgroup with rigorous entry criteria, extended training and use of a specific title (Nancarrow and Borthwick 2005). Historically, nursing and the allied health professions have had a ‘less formal system for recognising professional specialisation’ than medicine (Nancarrow and Borthwick 2005: 907).
Attempts to define advanced and specialist nurse practitioner roles and to establish meaningful regulation appropriate to varying levels of practice have proved problematic (Furlong and Smith 2005, Royal College of Nursing 2010). Without separate recognition on the nurse register for advanced nurse practitioner roles, alongside the reluctance of the Department of Health to establish further annotations, there remain no recognised minimum training standards for nurses working at advanced practice level (Waters 2011, Wilson and Bunnell 2007). Yet several specialist areas of practice in nursing exist where advanced practitioners are deployed in the absence of uniform standards (Srivastava et al. 2008), such as in cancer care nursing (McLoughlin et al. 2012), perioperative and surgical care (Abraham 2011), critical care (Fleming and Carberry 2011) or diabetes care. Although the ‘diabetes specialist nurse’ role was initially defined by the Royal College of Nursing in 1991, and endorsed following review by Diabetes UK in 2010, no associated, formally recognised professional certification underpinning appointments to the role have been established at regulatory level (Llahana and Hamric 2011).
In medicine itself the emergence of specialist practice has often been considered a result of jurisdictional boundary disputes rather than one of unproblematic or natural evolution in which claims are justified on the grounds of skills, expertise, knowledge and competence, alongside enhanced patient benefit and organisational efficiency (Abbott 1988, Pickard 2010, Sanders and Harrison 2008, Zetka 2011). At an inter-professional level strategies for adapting to workforce redesign pressures have included the negotiation of role settlements (Weiss and Sutton 2009), the redefinition of professional and organisational identities (Carmel 2006) or contested boundary encroachment where competing legitimation discourses vie for ascendancy (Borthwick et al. 2010, Sanders and Harrison 2008, Stevens et al. 2007, Timmons and Tanner 2004). In addition, for the allied health professions, medical dominance remains relevant and demonstrable, even if it is less potent than was once the case (Allsop 2006, Borthwick et al. 2010, Coburn 2006, Larkin 2002, Willis 2006).
For Zetka (2011), official speciality recognition in medicine became necessary only when dominant groups were threatened by challenges to their core skill or logic. Parallels exist in the challenges to medicine from the allied health professions, although these are contextually distinct because of medicine’s established hegemony and dominance (Borthwick 2000, 2001, 2005, Borthwick et al. 2010, Larkin 1983, 1988, 1995, Turner 1995). Although official speciality recognition is better established in medicine than in other health professions, consultant-level posts and extended scope roles have become increasingly evident across the allied health profession, ranging from physiotherapy (Kersten et al. 2007, Oldmeadow et al. 2007), radiography (Cowling 2008, Hardy et al. 2008, Price and La Masurier 2007) and podiatry (Borthwick et al. 2010, Isaac et al. 2008) to optometry (Needle et al. 2008) and dietetics (Skipper and Lewis 2006). Using the allied health profession of podiatry as an exemplar, and drawing theoretically on Weber’s concept of charismatic authority, this article explores the way in which specialisation in one particular field of practice emerged through informal means, and examines the nature of the relationship between it and its formal counterpart speciality in medicine.
Role boundaries and specialisation within podiatry
Larkin (1983) described the way in which the allied health professions historically emerged within, and adapted to, a hierarchical health division of labour characterised by the pre-eminent social and cultural authority of medicine (Freidson 1970, Larkin 1983, Ovretveit 1985, Turner 1985, 1995, Willis 1983, 2006). Each undertook organised attempts to professionalise, against a backdrop of medical resistance and exclusion, achieving, by 1960, a degree of formal recognition as professions ‘supplementary to medicine’ (Larkin 1983). One of those professions – podiatry – later attempted various forms of specialisation as part of its professional project, encroaching upon the role boundaries of medicine in the process; a strategy adopted in both the UK and the USA (Borthwick 2000, 2001, 2005, Chumbler and Grimm 1992, Larkin 1983, Skipper and Hughes 1983, 1984).
The recognition of the importance of specialist skills and knowledge to the professional advancement of podiatry led to the establishment of a limited number of more formal (and exclusive) roles, such as in ‘podiatric surgery’, involving a ‘slow arduous process’ to acquire skills and practices once exclusive to, and often bitterly contested by, medicine (Borthwick 2000, 2001, 2005, Chumbler 1993, Chumbler and Grimm 1996: 61). However, most other speciality areas of practice in podiatry remain informal (Nancarrow and Borthwick 2005). One such example is to be found in the field of diabetes care. Diabetes mellitus is a disorder associated with long-term complications that affect the feet, and the contribution of podiatrists in both preventing and managing these complications has long been acknowledged (Carls et al. 2011, Diabetes UK 2009, Keen 2000, Lorimer 1995, World Health Organization and the International Diabetes Federation 1990). As this article seeks to explore, the attempt to establish this field of practice as a speciality within podiatry constitutes an example of a more informal system of recognition; one that hinged upon the role of charismatic professional leaders, and which invites parallels with Weber’s concept of charismatic authority.
Weber’s charismatic authority
Within his conceptual framework addressing individual and organisational social action, Weber considered three forms of authority: traditional, rational-legal and charismatic (Roth and Wittich 1978), which constitute the political means of occupational control. While the authority of most contemporary professions largely resides in a rational-legal form – a transition from tradition that enables the pursuit of social closure (MacDonald 1995, Murphy 1988) – it is argued here that charismatic authority also has a place in explaining certain facets of modern professionalism. A number of analyses of professions have utilised Weber’s notion of social closure to indicate the processes by which they act, as social collectivities, ‘to maximise rewards by restricting access to resources and opportunities to a limited circle of eligibles’ (Parkin 1979: 44). For the professions, strategies are deployed that aim to ensure economic and social rewards, such as exclusive market control over service provision, high social status and remuneration. Social closure is most evidently expressed by the professions through credentialism and legal monopolisation (MacDonald 1995, Parkin 1979, Saks 1983). Recently, however, the applicability of the concept in healthcare has been viewed as ‘radically incomplete’ (Coburn 2006: 441). In contrast, few recent studies have sought to explore the potential applicability of Weber’s charismatic authority in a healthcare setting.
Drawing on earlier theological roots, Weber (Roth and Wittich 1978) argued that an interpretive understanding of the actions and beliefs of individuals, and multi-causal modes of explanation, are crucial in understanding society (Kalberg 2005, Scaff 2008). Although Weber applied the notion of charisma in both religious and secular contexts, it is the latter context that is relevant to this article. For Weber, authority1 implies the probability that a defined group of individuals (as a result of a variety of motives) will orientate their social action towards giving directives or commands and that another definable group will orientate their social action towards obedience (Kalberg 2005). Charismatic authority thus confers a cultural and social authority on the leader, where directions or commands are accepted and followed – not because they are necessarily perceived as being correct or legal (rational-legal), or that they adhere to what has always been done in the past (traditional), but because the assertion made is imbued with the leader’s authority.
For Weber (Roth and Wittich 1978), the charismatic leader is able to inspire others, lead change and set aside existing rules (Giddens 1971). The authority of the leader is dependent on its acceptance by the followers, a ‘willingness to obey … by virtue of which, persons exercising authority are lent prestige’ (Weber 1968: 263), a point that resonates with Gramsci’s notion of hegemony, where authority is given legitimacy by those who are subject to its effect (Anderson 1976, Boothman 2008, Femia 1981, Ives 1998). Central to the maintenance of this authority is the successful exercise of its claim –‘so long as it is proved’– and the implicit belief that the authority is justified (Giddens 1971, Kalberg 2005, Weber 1968: 52).
Motives for compliance by adherents can be diverse, ranging from habit to a purely rational calculation of advantage (Roth and Wittich 1978: 212). Because charismatic authority rests almost entirely with the leader, it is idiosyncratic and often without formal organisation (Weber 1968). Its only source of legitimacy derives from a personal aura of authority, which must constantly be demonstrated, yet maintained without coercion (Weber 1968). Thus, critically, the perceived legitimacy upon which charismatic authority rests can be undermined by the loss of the leader’s charisma, by prolonged personal absence or by the weakening of loyalty in the followers; thus charismatic authority tends to be particularly unstable (Roth and Wittich 1978). Absence or loss thus requires a replacement if an organisation based on charismatic authority is to continue to function (Eisenstadt 1968, Ritzer and Douglas 2004).
Ultimately, the process of routinisation is thought to remodel this form of authority, becoming either rationalised or traditionalised (Ritzer and Douglas 2004), with the formation of either traditional norms or legal rules (Giddens 1971). The process of the routinisation of charisma may differ greatly among different institutional settings (Eisenstadt 1968): the resultant form of authority relationship established is considered to be dependent on how the problem of succession is resolved (Giddens 1971). For example, if either hereditary or appointed leaders succeed a traditional status group is formed; where leadership is linked to qualifications a rational-legal type of authority tends to emerge (Giddens 1971, Weber 1968). Indeed, in the long term, most ‘disciples’ will make a living from their calling (Weber 1968). Followers may set up norms for recruitment, involving training or tests of eligibility. However, Weber maintained that charisma itself cannot be learned or taught, only awakened or tested (Weber 1968). It is only where charismatic authority becomes transformed into routine or traditional authority, and is thus no longer a personal force, that it can be regarded as something that can be linked to a process of education (Giddens 1971). Thus, in the current study, Weber’s charismatic authority represents an orientating theory with relevance in historical and contemporary contexts at both micro and macro levels.
Ethical approval was gained from the internal ethics committee of the University of Southampton. Utilising podiatric specialisation in the field of diabetes as an exemplar, the study commenced with a concept analysis. Allied to, but differing from, the literature review, conceptual analysis involves interrogating the literature as though it were data. In line with contemporary practice, the Morse (2000) model was adopted, which prioritises cognitive processes over rigid, systematic evaluation (Paley 1996, Rew 2005, Rodgers 2000, Weaver 2005). The analysis of concepts related to the concept of interest (after Rodgers 1993), namely ‘diabetology’ (medical specialisation in diabetes) and ‘diabetes specialist nursing’, captured other healthcare professions’ practice for comparison. The concept analysis exposed ‘diabetes specialist podiatry’ as an immature concept with variable pre-conditions, characteristics and outcomes.
Semi-structured interview schedules informed by themes elicited from the literature and concept analysis guided the interviews. The initial participants were four executive committee members of Foot in Diabetes United Kingdom (FDUK) and ten members of the Society of Chiropodists and Podiatrists Faculty of Management. A snowball sampling strategy identified further key informants, including one each from government and professional bodies, three senior consultant diabetologists (medical doctors specialising in diabetes) and nine specialist podiatrists. The interviews were audio-recorded and data transcribed verbatim then analysed, utilising constant comparison within a thematic framework; as far as possible minimising the effects of the researcher’s existing knowledge as a podiatrist with an interest in specialisation. An inductive methodology and the process of constant comparison ensured that the researcher considered much diversity in the data (Glaser and Strauss 2006), with emerging themes being continually developed and checked for relevance. Finally, content analysis entailing the examination of historical journals spanning some 55 years of podiatric practice was utilised as a triangulation strategy. Providing a systematic, reproducible method of analysing text, allows the corroboration of findings from other forms of data collection (Krippendorff 2004, Yin 1994) and is frequently used to enrich other qualitative methods (Hodson 1999, Love 2003).
The findings illustrate the importance of charismatic authority in the establishment, development over time and current status of diabetes specialist podiatry. The iconic status of a few key diabetes podiatrists has made their names recognisable throughout the profession. Reference to these individuals in the data has been retained. Finally, problems associated with a specialty founded on charismatic authority are presented and routinisation strategies discussed.
Charismatic authority and the ‘diabetes specialist podiatrist’
In medicine, eligibility to apply for a specialist or consultant post is bound to a defined period of training and the attainment of recognised, validated qualifications. Thus, while diabetologists (medical consultant specialists in diabetes care) may be charismatic individuals, their roles, titles and positions are legitimated by rational-legal authority. In contrast, podiatric specialisation in diabetes care lacks clear preconditions. The specialty is only loosely underpinned by limited sections of health policy, embedded in national service frameworks (Department of Health 2001, 2002, 2008b) and clinical guidelines (Diabetes UK (2009), Foot in Diabetes UK et al. 2006, National Health Service [NHS] Clinical Governance Support Team 2006a, 2006b, National Institute for Health and Clinical Effectiveness [NICE] 2011, 2004, Scottish Intercollegiate Guidelines Network 2002). Eligibility to apply for a podiatry post specialising in diabetes care is not linked to any educational or experiential prerequisites, and those in post display wide variations in qualifications. The absence of formalised, accredited educational preparation for specialisation or any established career pathway excludes legitimation based upon rational-legal authority. However, by utilising charismatic authority, a group of practitioners was able to establish specialised practice within the field of diabetes foot care. Study participants highlighted the centrality of iconic individuals who were innovative in practice and established specialist skills distinct from those of other podiatrists and who, via their interactions, publications and presentations, raised the profile of diabetes podiatry as a specialised area:
You know there were a few icons like Ali [Foster] and she knew, well bless her she was, she is, really is iconic and putting us on the map. (SS2 59–61)
… podiatrists play a pivotal role in it and I think if we look back to 1989, the paper that Alistair [McInnes] was involved in with Mike Edmonds et al., that St Vincent’s’ paper. (International Society for Pediatric and Adolescent Diabetes 334–7)
Those considered to be pioneers in diabetes podiatry showed innovative approaches to skill acquisition, funding and accessing education:
Another key moment was when I had a long chat with Ali Foster and we were talking about how she’d got certain skills and where did she get them and getting bits of money, self-funding, off to America. I remember asking her to talk about where she got her plaster casting techniques from and the skills, and it was when she spent time in the States. (JH 11–16)
Thus, by importing what they had learned, they influenced practice, extending its scope and establishing novel, specialised activities. Lindholm (1992) pointed to the ‘infectious’ nature of the charismatic’s enhanced vitality, which is communicated to the audience. The charismatic podiatrists utilised this, disseminating knowledge and gaining disciples through conference presentations and textbooks, sometimes with medical co-authors:
… there have been a few of us who have been very active in research which also allowed us to present at national and international meetings which has then raised the awareness of the skills of podiatry to the point now where I would say that the podiatrist is actually pivotal in all of the diabetic foot clinics. (CG 125–9)
Reflecting the political nature of the professional project, linked by Larson (1977) and MacDonald (1995) to the formation and nurturing of relationships with strategic allies and sponsoring elites (Freidson 1970), the podiatrists used their charisma to secure medical support. By demonstrating knowledge, clinical skills and public confidence, they bolstered their claims to authority, securing the support and acceptance of diabetologists, without recourse to formalised credentials or titles:
Once upon a time Ali Foster… maybe one or two others, were the kind of sole representatives … the drivers of things because we could hold our own in that environment I suppose, we could get up and speak and, and slowly … when they were accepted as members of the diabetes team and presented well and knew their stuff, they were then accepted by the other members of the medical team and they then helped to support podiatrists. (JH 133–142)
The medical diabetologists acknowledged the role of charismatic podiatrists in developing joint clinics and actively seeking medical support:
individual podiatrists with in an interest in pushing the boundaries a bit … a group of us that were interested in proving that the diabetic foot clinic could work and we gave our service for free for 6 months to show that it could work, and it … convinced people that it worked and so that was a big influencing factor. (Expert reference group 355–64)
Contemporary charismatics – agents for change
The phenomenon of succession is evident in the transition from early icons, who established diabetes podiatry, to later key leaders and champions who sought to develop the specialty. Contemporary leaders have challenged the practice and models of the early iconic individuals in order to exert a broader, cross-professional influence on standards and governance:
Ali has done marvellous things. I think the time has changed and there are now a couple of key leaders or a few key leaders in the diabetic foot who are equally driven as Ali but … have a wider view … we’re gonna [sic] look at the diabetic foot full stop, whether you’re a nurse whether you’re a doctor, whether you’re a podiatrist and we [want to] look at the whole thing and create the right environment for people to progress and develop … within that role. And also to set the standards … nobody was setting the standards. (CG 1042–1058)
The charismatics’ authority was justified through research and clinical outcomes, linking activities to reducing amputation rates. Conference presentations and publications ensured a wider base of support:
We were one of the very, very early foot clinics and after a couple of years we had demonstrated a 50 per cent reduction in major amputations and we were all very, very conscious of the need to promote the profession, you know, and we had a lot of publications, a lot of presentations at Diabetes UK and so I guess we won the respect of our colleagues and that was how it [practice] changed. (PL 52–58)
In acting as agents for change, the ability to challenge medical practice was highlighted:
Actually fighting the cause, which is saying to some [medical] consultant, I do not agree with you, you are wrong … has taken about 20 years. (CG 136–140)
These accounts provide an illustration of the way in which, once established, charismatic authority tends to challenge the traditional or rational-legal authority that enabled its very evolution. For Weber the resolution of this form of challenge is achieved through a process of routinisation.
Charismatic authority; tensions, limitations and constraints
Diabetologists recognise the potential for conflict with the charismatic leaders in diabetes podiatry:
Our podiatrists could get, stroppy … you know, all the patients, essentially, are under my name and you know, some stroppy podiatrist might say ‘Ah, I’m doing all this work, you know, I ought to have my name on these people’. (IM 518–520)
Given that charismatic leaders in diabetes podiatry now view challenging medical practice as part of their remit, two key factors appear to prevent them from mounting a jurisdictional claim over the treatment of diabetic foot disease; the ability of medical doctors to contain the podiatrists’ charismatic authority and the podiatrists’ continuing need for a powerful sponsoring elite. A lack of formal admission rights and their status as supplementary prescribers constrains their role, ensuring their continued dependence upon medical colleagues:
At the moment, I don’t think they’d have the sort of … political power to arrange for the admissions. Which might get very frustrating. (IM 187–189)
Based upon the re-proven abilities of the practitioners involved (a necessity for maintaining their charismatic authority) an approximation to admission rights for one group of diabetes podiatrists had been achieved through the negotiations of one diabetologist, albeit unofficial:
I negotiated direct referral rights to our emergency medical unit for the podiatrists … one of the swinging factors was, I told them, the quality of the referrals you’ll get from those podiatrists will exceed most GP referrals. (AT 480–487)
Similarly, the legally restricted prescribing of medicines hampers the podiatrists and ensures they are dependent upon medical support to fulfil certain roles, and this limits their role expansion in key areas of practice. Although able to access medicines through mechanisms such as ‘patient group directions’ or ‘supplementary prescribing’, both require medical endorsement:
No, podiatrists can’t be independent prescribers yet … it has to be supplementary prescribing, which means that I have to agree the care plan. (AT 92–93)
While those podiatrists who seek the continued development of diabetes podiatry still display and use charismatic authority, there is a recognition of its fragility:
… there is not an Ali Foster in every part of the UK. You know, there’s not a Louise Stuart, there’s not an Alistair McInnes … this is what I guess concerns me … what I’d like to see happen within our profession is a vehicle to allow people to progress there, because when certain folk retire, who’s [going to] be the ambassador for podiatrists in the diabetic foot? (CG 765–773)
Routinisation – the replacement of charismatic authority by a more stable form of authority – is evident at many levels. At the direct patient-contact micro-level, the transition from charismatic to rational-legal authority is accomplished via the use of tools such as care pathways:
It’s so simple to put a care pathway and get it through the governance structure … Such a simple mechanism is effective … Without a care pathway, you might have a passionate individual like … a Louise [Stuart] or an Alistair [McInnes] or whatever … you refer to Alistair or Louise, they’re good at it, what happens if I die, what happens if I leave? (SS 489–509)
Specific reference to podiatry in the NICE guidelines for diabetes represents evidence of the macro-level routinisation that has been achieved (NICE 2011). At the strategic, macro-level further routinisation is underway; as evidenced by the creation of a national minimum skills framework for commissioning of foot care services for people with diabetes (Foot in Diabetes UK et al. 2006), established in response to what was perceived to be an inadequate existing framework created by Skills for Health:
I don’t think it’s [the Skills for Health Diabetes Framework] much help to us … the whole reason why we did the minimum skills framework was because it was inadequate. (SS 673–676)
The production of the national minimum skills framework represents the formulation of health policy at national level by Foot in Diabetes UK. This was achieved via the use of inter-agency cooperation and endorsed by Diabetes UK, the Association of British Clinical Diabetologists, the Primary Care Diabetes Society and the Society of Chiropodists and Podiatrists. Having established the national minimum skills framework, Foot in Diabetes UK is now turning attention to the education and assessment of diabetes specialist podiatrists:
The future needs to have … a definite exam system and structure, so that people are then at least potentially entering these posts with a good knowledge and understanding. (MP 284–286)
In this way those diabetes podiatrists who see themselves as leaders are utilising a powerful sponsoring elite to support their formulation of health policy and endorse the development of education and career pathways; representing significant further routinisation at a strategic, macro level.
Although the near universal legitimacy of bureaucratic processes in contemporary healthcare may cast doubt on the relevance of charismatic authority, this study suggests the latter retains explanatory utility in respect of the case presented. It is accepted that, rather than representing an attribute of personality, charismatic authority rests on a social recognition of a claim. The first iconic diabetes podiatrists, drawing a following from other podiatrists, established an area of practice based on knowledge, clinical skills and working practices that differed from other podiatrists. Subsequently they were able to legitimate, disseminate and defend their practice in the absence of formalised qualifications or established career pathways; effectively launching a formalised specialty in their own profession based on charismatic authority.
However, the apparent equality attained by the iconic podiatrists with their medical consultant colleagues was perhaps less tangible than it may have appeared at face value. Medical doctors made use of the charismatic authority of the iconic podiatrists, working within what they considered to be their teams, thus benefitting from association with their iconic podiatrists, which reinforced the status and importance of the diabetic foot team. The podiatrists were not, however, simple stooges; in cultivating an association with medicine they gained powerful sponsorship and enhanced their (vicarious) legitimacy. Though diabetologists recognised the potential for conflict with these charismatic individuals, it seems that while the authority of the podiatrists remains limited to the sphere of podiatry, medical support for them is likely to continue. Perhaps the dependency of their charismatic authority on the need for a powerful sponsoring elite may be what, in part, prevented the diabetes podiatrists from challenging the medical leadership of diabetic foot teams and mounting a jurisdictional claim over the treatment of diabetic foot disease. Medical hegemony is retained as a form of social authority that is not undermined by the charismatic authority of the iconic podiatrists, but, rather, is promoted by it.
The recognition of the fragility of their charismatic form of authority has led key podiatrists – notably Foot in Diabetes UK executive members – to seek more stable and formalised legitimacy for diabetes podiatry. In the process of routinisation, charismatic authority is replaced by a bureaucracy controlled by a rationally established authority or by a combination of traditional and bureaucratic authority (Weber 1968). This routinisation is evident at many levels, from the use of local health policy in the form of care pathways by individual podiatrists to the production of national policy by Foot in Diabetes UK. These pathways and policies not only represent what Montgomery (2003) calls ‘quasi-law’, which inevitably impact on the clinical activities and caseload of podiatrists, they also form further key legitimising strategies for diabetes podiatry via the establishment of rational-legal authority. Care pathways form a particularly ingenious approach: while to a certain extent they codify knowledge; more importantly, they have been used to shape and direct the clinical activity and referral patterns of other health professionals. In this way care pathways have been used to strengthen the jurisdictional claims of diabetes podiatrists over the control of managing diabetic foot disease.
Changes over time and contemporary practice have been shaped by national and local health policy, the influence of medical dominance and the negotiations and professional project of podiatrists. However, charismatic authority has proved to have continuing relevance in the ongoing development of the specialty at micro and macro levels. It represents an orientating theory that is not in competition with the concepts of medial dominance, professional projects, jurisdictional claims or professional closure. Rather, it provides a potent explanation for how the diabetes podiatrists have been able to establish, develop, disseminate and legitimate a clinical specialty in the absence of both underpinning credentials and a recognised career pathway. Routinisation strategies represent contemporary attempts to secure a legitimate long-term future for diabetes podiatry as an identified specialty. The case of the diabetes specialist podiatrist illustrates an explanatory role for charismatic authority, not previously discussed, adding to the literature in the under-debated area of healthcare specialisation.
Some confusion exists regarding the Weberian notion Herrschaft, which has been translated as both authority and domination. This derives from the ambiguous nature of Herrschaft– which, as Kalberg (2005) notes, implies an element of force and domination, combined with legitimacy, but for which no exact English translation exists. In English texts it has in the main been translated as authority and this is the term used by this author.
Pseudonyms were assigned to the interviewees during the study. SS, CG, PL and MP were specialist podiatrists, IM and AT were diabetologists. We are very grateful for their participation in the study.