Professional roles are blurringBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.a3163 (Published 07 January 2009) Cite this as: BMJ 2009;338:a3163
From community specialists to nurse consultants, traditional job boundaries are blurring. Kathy Oxtoby takes stock of the profession
Time was when consultants were gods and general practitioners were demigods. Nurses were handmaidens ministering to the needs of these deities, while pharmacists stuck to selling plasters.
Crude as the depictions might be, as with any stereotype there is a glimmer of truth to them. In the early days of the NHS, every healthcare professional knew his or her place. But over the years there has been a gradual blurring of roles, as each profession takes on tasks that were once the responsibility of those classed above them in the healthcare hierarchy. Pharmacists are screening, nurses are prescribing, GPs are specialising, and consultants are increasingly taking on managerial roles.
The government wants and expects healthcare roles to blur still further to fulfil its vision of the professions working together under one roof in polyclinics or GP led healthcare centres. David Grantham, head of programmes for NHS Employers, says extended roles are vital for helping the NHS cope with increasing demands and for giving people the opportunity to develop their skills.
“Productivity is key to delivering the healthcare needs of an ageing population. If we use skills mix and extended roles sensibly and appropriately we can improve productivity and increase job satisfaction,” he says.
While the government would like to see doctors, nurses, and pharmacists working together in harmony, a note of discord is coming from those who would prefer to stick to doing what they do best and for others to do the same.
Peter McDonald, a consultant gastrointestinal surgeon in London, suggests that the drive to blur healthcare roles is “all about money.”
“It’s cheaper to extend roles, but in the end patients will be worse off,” he says. He believes this is because, while nurses “follow protocols very well—better than doctors,” they are not trained to make decisions when there is a problem that falls outside of that protocol. If all health care becomes protocol led this could be “dangerous for patients because protocols do not cover all eventualities,” he suggests.
Sunderland GP Phil Peverley believes extended roles are “no substitute for years of medical training. It’s de-professionalising doctors to say that everybody can do what we do, and it’s madness to suggest that someone is an independent practitioner unless they have had anatomical, pharmacological, and physiological training.”
One reason why GPs “get tetchy” about extended roles is that they “tend to deconstruct our job,” says Keith Hopcroft, a GP in Basildon. The more the role of other healthcare workers extends, he says, the more his role “either shrinks or shifts into other territories.”
“Practice nurses becoming the first point of contact for some conditions leaves GPs having to specialise—so why become one? Or having to deal with all the tough stuff or preventive health care.
“So by default we become a public health doctor or primary care consultant physician. And that wasn’t what it originally said on my job description,” he says.
Healthcare professionals are being encouraged—some might argue pushed—to do above and beyond what they originally “signed up for.” Dissenters from all professions have dubbed this a cheap and illusory way of appearing to expand services. And both the nursing and pharmacy unions have raised concerns about increases in workload not being matched by equivalent rises in funding.
While not everyone is happy to extend their roles, many have embraced these new career opportunities because they believe they can increase patient access and choice, boost job satisfaction, and help tap into what was previously unfulfilled potential.
As a nurse specialist for cardiac homecare surgery in London, Philip Walters’ role would traditionally have required doctor input. Instead, his post, which focuses on optimising preoperative and postoperative care, gives him “autonomy and influence on patient experience. It means I can take patient care beyond ‘holding their hand,’” he explains.
Cardiac surgeons supported the new post he says. “They could see the benefits of creating a safer operative process. My role isn’t ‘treading on toes’; it is helping doctors as well as patients.”
Ironically, he has, on occasion, experienced more suspicion about his role from nurses than from doctors. “Some believe in guarding their role and think nurses should focus on nursing,” he says.
As a pharmacist concerned with smoking cessation and supplying emergency hormone contraception—both previously the job of GPs—Middlesbrough pharmacist Michael Maguire has had negative feedback from elsewhere within the medical profession. He says he once “received a put down” by a GP for his achievements and has had “sarcastic comments” about his work from a consultant.
That said, the more healthcare committees he attends and the more doctors he speaks to, “the more they get to know about the work we’re doing, and the more they embrace what we do.”
Clearly there is a divide between those who want healthcare roles to stay the same and those who want change, and this seems to be causing tension between healthcare professionals. Mr Walters has noticed “some friction between senior nurses and junior doctors, who may be unaware of these nurses’ capabilities and are therefore inclined to be less trusting of them.” And Mr Maguire believes extended roles “have the potential to cause more friction between healthcare professionals.”
But the government will not allow this difference of opinion to stall its plans of multidisciplinary team working. Mr Grantham says: “People might be territorial, but things will need to change to make the NHS work in the next 10 years.
“With the demands on NHS services and the reduction in NHS finances, the next step will be to look at whether other staff can take on different tasks.”
If people don’t embrace new roles, Mr Walters believes the government’s healthcare reforms won’t succeed because “everybody has to be on board to make them work.”
Without nurses to fill the gap, he says doctors cannot meet the predicted increase in workload and that as a result, patients’ quality of care could suffer.
He believes there should be “no restrictions as to how far these roles can be developed” and that every nurse specialist should be allowed to develop within their own potential. “If people have the ability to do these roles, why shouldn’t they?”
Mike Dixon, chairman of the NHS Alliance agrees. “If someone is up to do the job they should be able to do it—and we shouldn’t worry about which ‘tribe’ they come from.” He urges the medical profession to “stop putting up barriers and look at what people’s capabilities and talents are.”
For extended roles to work, Mr Maguire says it is “essential that each healthcare professional operates within their competencies.” He also believes that improving communication among the professions would encourage better work relationships and trust in each other’s skills and abilities.
Richard Vautrey, deputy chairman of the BMA’s GPs committee, says it is inevitable that people will feel anxious about others taking on their traditional roles. However, change in health care is also inevitable, he believes. “Medicine has evolved over the centuries and will continue to do so.”
He warns that, while extended roles might seem like a more cost effective way of delivering services, “this should not be at the expense of quality of patient care, which we must retain at all costs.”
And he stresses it should be made clear to patients the status of the healthcare professional who is treating and advising them, to avoid confusion about their roles and responsibilities.
Mark Porter, deputy chairman of the BMA’s Central Consultants and Specialists Committee, calls for a reasoned approach to extended roles. “You can take things too far. It would go beyond common sense if it no longer mattered whether people with complex diseases were being treated by a consultant, GP or specialist nurse,” he says.
As to whether people carrying out extended roles is in the best interests of the patient, the answer, as ever, seems to fall between the two opposing views—a compromise that recognises their limitations as well as their value. As Dr Hopcroft puts it: “If blurring and extending roles is just blindly pursued because it’s ‘the new beige,’ then it runs into all sorts of problems and resentments.
“But if it’s focused and addresses a real need in a sensible, structured way—then what’s not to like?”
Jane Warner is a senior practice nurse and educationalist in Devon. She says:
“One of the reasons I fell in love with practice nursing was because there are opportunities to develop your role, which is something I’m always trying to do.
“As well as teaching new practice nurses in the area, I carry out long term condition and acute illness management and telephone triage—all things GPs do.
“Two years ago I decided to become a nurse prescriber. I’m fortunate that I work for a progressive practice—I was encouraged by all the GPs there, who were very supportive. One became my mentor and I learned a lot from him.
“It’s not so much about what I get out of doing these extended roles as what patients get—quicker access to medicine, improved access to services and, arguably, a better use of my professional skills.
“I keep reading in the medical press comments akin to the fact that it would be safer for a nurse to wield a flame thrower in a petrol station than to allow one to wield a prescription pad and pen. But nurses are accountable for their actions and omissions. We never prescribe outside our area of competence, and we always follow our patients up.
“To those who argue ‘stick to what you do best’ I’d say that I’m not trying to be a mini doctor, I’m trying to be the best nurse I can be.
“While differences in opinion about extended roles might mean there is more opportunity for friction between nurses, doctors and pharmacists, this conflict has always existed—it’s just the way of the world.
“But however much we argue we should remember we’re all on the same side—the patient’s side. They should always be our main focus, whatever our role.”
Competing interests: None declared.