Published: 04/07/2002, Volume II2, No. 5812 Page 18
What defines doctors and nurses? The way nurses are impeccable team players and doctors hopelessly non-corporate? Or does something deeper distinguish the two groups? The question is real, given the changing nature of the NHS and the capacity problems it faces in the growing list of central imperatives and directives.
Faster and more technical hospital throughput cannot be met in traditional ways; increasing demand at the 'front end' requires different solutions; and in organisational terms, the possible introduction of a socalled new GP contract signals a change in the relationship between the two professions. The contract is 'so-called' because its reality (if fully implemented) would mark an end to the NHS holding contracts with individual doctors, instead agreeing contracts with whole organisations. That would allow each organisation more freedom to define its own skill-mix, and perhaps encourage us to think why we choose doctors or nurses in particular circumstances.
At the very least, doctors and nurses have varied considerably in their traditional tasks, training, and the way they have worked. Doctors'work has historically been rooted in the diagnostic process: history taking, examination, the integration of many subtle signs and symptoms, words and body language, context and 'hunch' that lead to the identification of 'dis-ease'which even now cannot easily be bettered by a computer.
The diagnostic process may be followed by a therapeutic intervention (especially where surgeons are involved), but the core of medical practice remains consultation and diagnosis.
Nurses have been mainly involved in the direct delivery of care, whether applying dressings, monitoring treatments or physically caring for ill people.
Their training has emphasised the skills necessary for this: more about operational techniques and less about balancing risks and probabilities; lots about hierarchy and relatively little about decision-making; much about team-working and hardly anything about independence.
How much of this divergence is related to organisational 'character' and how much to the personality of the caricatured doctor and nurse is a moot point; once the stereotypical models were in place, they probably attracted like-minded people who then reinforced the pattern.
These role differences were reflected in training: doctors trained to be independent, with little external accountability.
Nurses were traditionally more corporate, hierarchical.
But now, everything looks set to change. Nurses are used at the 'front end' of the system, doing triage, making diagnoses, deciding on treatments, while doctors are expected to conform with guidelines, think more corporately, and become ever more technically proficient.
The question not asked is whether it is more sensible to create new paradigms of care delivery or work within existing patterns of behaviour. Doctors have to start being a bit more corporate in behaviour and accountability.Clinical governance reaches to the heart of the system/patient relationship, and acknowledges that modern healthcare can only be delivered effectively if a team approach is taken.
Similarly, nurses are breaking out of their quasi-military straitjacket - also long overdue.
But compliant medics exercising no initiative and taking no informed risks would be almost as useless as a bunch of individualistic free-ranging nurses, so both groups have to change to keep the baby of quality while discarding the bathwater of professional vanity.
Healthcare needs three outcomes from this professional reconfiguration: to cover the skill shortage, to balance corporacy and individualism among all clinicians, and to preserve and perhaps strengthen the idea of care management, which underlies the NHS.
Let informed, caring doctors, nurses, or other professionals oversee each NHS user's journey through the system, co-ordinating care delivery, explaining pitfalls, and keeping 'ownership'of the process - not just in disease terms, but each client's human characteristics.
The NHS should capitalise on the best ways of treating people, rather than the technical excellence of the way it handles disease.And whether it is a doctor or a nurse, or some hybrid of the two who is involved, will be irrelevant compared to the quality of care they give.
Jonathan Shapiro is a senior fellow at Birmingham University's health services management centre.
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