Intended for healthcare professionals

Education And Debate Modernising the NHS

Challenges to the health services: the professions

BMJ 2000; 320 doi: (Published 03 June 2000) Cite this as: BMJ 2000;320:1533
  1. Isobel Allen, professor of health and social policy (i.allen{at}
  1. Policy Studies Institute, London NW1 3SR

    This is the fourth in a series of seven articles

    “There is the challenge for the professions to strip out unnecessary demarcations, introduce more flexible training and working practices and ensure that doctors do not use time dealing with patients who could be treated safely by other health care staff.” This was the third of five challenges to the health service set out by the prime minister on 22 March, followed up by the secretary of state for health on 23 March with the announcement of six modernisation action teams to focus on the challenges. This announcement expanded on the reference to more flexibility and removing demarcations by adding “in the context of major expansion of the health care workforce.”

    The challenge to the professions has been made. What are the most important things that would make a difference?

    Summary points

    Professionals are ready to change—and have already done so

    NHS organisations need to listen to their staff, who know where systems go wrong

    More flexible working and training are long overdue, together with proper training for multidisciplinary working

    Innovation needs to be encouraged—and entrepreneurial clinicians supported

    Preparing to act on the challenge

    The first thing is for the government to recognise the extent to which members of the professions are ready to take on the challenge. The profile of the medical profession has changed radically in the past 10 years. Women now account for more than 50% of doctors leaving medical schools 1 and represent an increasing proportion of doctors under the age of 40, particularly in general practice. Younger doctors are much more like their contemporaries outside medicine in terms of education and aspirations than their older counterparts were.2 They deplore the traditional resistance to change of the medical profession. They want flexibility within their careers which will help them to lead a “normal life.” And they find it absurd that they waste their time in performing mundane and repetitive tasks that do not require their level of skills. They are only too ready to delegate these tasks to anyone who can perform them safely.

    But at the same time young doctors adhere closely to the core values of the medical profession.3 They are committed to caring for patients with compassion, integrity, competence, and confidentiality, but they balance the demands of this commitment with the benefits of the autonomy that has traditionally gone with their professional training and status.4 The challenge to the government is how to keep these young doctors on board at a time when they feel that they are being castigated for not being “modern” enough yet are working in a health service that seems to offer them little in the way of modern technology and administrative support—or appreciation of their commitment.

    Acting on what the workforce says

    The second most important thing that would make a difference is for the chief executive of each trust and health authority to listen to what people in the workforce say and to act on it. Clinicians and nursing staff have clear ideas of what is wrong with the present system—but junior medical staff have great difficulty in getting their voices heard. The fear of the adverse reference and being termed a troublemaker are still potent forces within medicine. Nurses speak with their feet; the problems of nursing recruitment and retention are not only related to pay. Consultants have more and more duties pinned on them, but they find that important, crucial decisions affecting how, when, where, and with whom they work are increasingly made by other people, both inside and outside the workplace. They feel that many of these decisions are eroding their ability to retain professional autonomy even within their clinical practice.5

    It is the people doing the work who are often most knowledgeable about duplication of effort, the inappropriate tasks, the nonsensical demarcation lines. There needs to be a review of the components of the jobs of both nurses and doctors to see what parts are essential and what parts could be done by others. Any preregistration house officer will speak about the boredom of doing repetitive tasks that could more productively done by nurses, phlebotomists, or clerical staff. Senior house officers are often performing service tasks that could equally well be done by others. There is a need for a reassessment of the consultant role to identify the core functions of the job, distinguishing these from other functions that need not necessarily be carried out by all consultants all of the time.5 The introduction of a “specialist” grade, as suggested in the recent consultation document on the review of workforce planning,6 would allow flexibility for many consultants who find the present “all or nothing” demands of the post intolerable. However, this grade must not be regarded as of lower status or as a “subconsultant” grade.

    Introducing flexible training and working

    The introduction of more flexible training and working is long overdue. The demand for more part time training posts in medicine was recognised 30 years ago, and schemes for enabling women “with domestic responsibilities” to train less than full time have been in existence since 1969.7 But the medical profession has been slow to embrace change, and rigid career structures that might have been suitable when the NHS was founded are still in place more than 50 years later.

    Embedded Image

    (Credit: ULRIKE PREUSS)

    Flexible training has now become accepted, but too much of it is still on a “grace and favour” basis; most posts are still supernumerary, and many of those contemplating such a move fear that they will not be regarded by senior staff as “proper” doctors.2 Only around 4% of junior doctors in the United Kingdom are in flexible training posts,8 and negative images persist among both consultants and junior doctors.9 But imaginative schemes for job sharing in training posts have been introduced successfully in one postgraduate deanery,10 and flexible training has been advocated by associate postgraduate deans for years.

    There are still far too many myths around about the disadvantages of “flexible” training, and every effort should be made to dispel them. This should not be regarded just as a “women's issue.” If women account for over half of doctors in training posts it is a complete waste of resources to put so many hurdles in the way of those who cannot work full time for the whole of their training period. It must not be forgotten that “part time” in medicine is often more than full time in most other jobs.

    Flexible working at consultant level has been the pattern for many senior members of the profession for years, and working less than full time is easier for many consultants than for their junior colleagues. A quarter of female consultants now work “part time,” 11 and there can be little doubt that the pump priming money of the Department of Health initiative in 1993 had an important influence in increasing the number of female consultants.12 The fact that the trusts have welcomed their contribution suggests that the management of part time consultants is not a major problem. It is certainly perceived as allowing trusts to draw on a wider range of high quality candidates.13 It should be encouraged and extended to doctors who are reaching the end of their careers and those who wish to train or retrain in their own or another specialty. Portfolio careers will soon be here in medicine too, and the days of 40 years in one place in one specialty are over.

    Using information technology

    There is a clear need for better information systems and better use of information technology within the health service. The inadequacy of even the most basic information about the workforce is of never ending surprise to researchers from outside medicine. And the use of computers and email within the health service still lags far behind the most ordinary office in the outside world. Good multidisciplinary working depends on good communication within teams and across disciplines.

    Encouraging entrepreneurship

    There is certainly a need to champion entrepreneurial clinicians who are leading the modernisation drive within the NHS and not to lose the support of those who are committed to providing a modern and dependable service.14 The motivation is there, but the professions need to be offered the means to implement change. If doctors are to delegate responsibility for patients to other healthcare staff they have to feel secure that those patients are going to be treated safely. And “safely” is the key word here.

    Improved training for the multidisciplinary team

    There is an urgent need for improved education and training for staff who could take on the functions of doctors within the multidisciplinary team. At the moment there are shining examples of good practice and multidisciplinary working, both in secondary and primary care. The use of specialist nurses in managing chronic disease and palliative care in the community is particularly well developed in some areas. But the pattern is much too patchy, and it is not surprising that so many doctors are unwilling to delegate functions when they are unsure of the skills of the staff to whom they would entrust the care of their patients. At the same time, many junior doctors are still performing tasks for which nurses have been trained but are reluctant to perform. Who is in charge of ensuring that this does not continue?

    Pushing the challenges too far?

    One of the main dangers in pushing the challenges to the professions too far is that practitioners will lose sight of the core values that brought them into medicine and nursing in the first place. If all the tasks are divided up according to a prescribed protocol so that it is quite clear who does what and when, there is a danger that clinicians will end up as “technical monkeys” who provide the drugs, the operations, and the interventions necessary to keep people alive longer,4 while nurses will struggle to reconcile the tension between advancing their technological skills and retaining their caring role.15 The challenge to the health service and the government is to balance the commitment and motivation of people who want to care with the demands of people who want to live for ever. Perhaps something has got to give.


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