Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Practising at the top of your licence

BMJ 2024; 384 doi: (Published 26 March 2024) Cite this as: BMJ 2024;384:q737
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on X @HelenRSalisbury

Doctors in every branch of practice grumble about time wasted trying to fix malfunctioning printers or scouring the workplace for the right blood bottle or pathology form. A well organised health service would have staff on hand to help with such tasks, as it makes no sense to use your most highly trained staff on work that could safely be carried out by someone with less training.

The idea of working at the top of one’s licence means just that—spending most of your time doing things that require your expertise. Not surprisingly, it’s an idea beloved of economists: why pay a doctor when a specialist nurse could do the job; why pay a nurse when the task could be undertaken by a healthcare assistant; and so on, right down to offloading work onto the voluntary sector, where no cost is incurred.1 Of course, the economic argument for this concept works only if doctors are appropriately rewarded for their skills and training, so it doesn’t always apply in English hospitals.2

There are areas of general practice where this role substitution is well developed. As a rule, blood samples are taken by a dedicated phlebotomist rather than a nurse, and tasks such as dipping urine specimens or recording ECGs are usually carried out by a healthcare assistant. This makes sense for practical tasks and for some medical consultations that can be carried out according to a protocol, which in most practices are now the responsibility of nurses.

However, there’s a risk of fragmented care and new inefficiencies when a patient makes multiple visits to the GP surgery, seeing a different member of the team each time. There’s a balance to be struck, as tasks that other staff members could do can sometimes be woven seamlessly into my consultations. I can take a blood pressure, do a pill check, discuss a recent mental health admission, look at a suspicious mole, and review the patient’s medicines all in the space of a single appointment. Looking after the patient as a whole, while paying attention to their physical and psychological needs in the context of their family and community, is what constitutes practising at the top of my licence as a GP, even if some individual components of a consultation don’t require my level of training.

The government’s long term workforce plan envisages a 49% increase in hospital consultants between 2021 and 20363—but only a 4% rise in fully qualified GPs, as noted by the National Audit Office this week in a critical report.45 This seems foolish, as for our health service to function efficiently what we need is more fully trained expert generalists providing continuity and holistic care.

We should take note of the results of a recent experiment in Mississippi, where replacing doctors with (cheaper) advanced nurse practitioners and physician associates as primary care providers proved to be an expensive mistake, resulting in increased testing and referrals, more emergency room visits, and worse medical care.6