open space

Are we making the best use of our limited supply of doctors? Charity work overseas suggests many tasks done by doctors can be tackled by others, says Paul Streets Perhaps we should not regard the references to the third-world NHS as entirely pejorative. In the mid-1980s I began work for Sight Savers, the healthcare charity supporting eye-care services in the world's poorest countries - in particular Africa and the Indian sub-continent. At the time, we were faced with a chronic shortage of ophthalmologists and a huge problem of curable cataract blindness. The answer was to train local paramedic cataract surgeons.

An American ophthalmologist, funded by Sight Savers, pioneered this in East Africa, working with African colleagues, and proved that clinical outcomes were as good as, if not better than, those achieved by ophthalmologists because the paramedics became experts in this one procedure. The idea built on the earlier development of trained and accredited ophthalmic assistants who could undertake a wide range of minor procedures, diagnose more complex problems and refer people on to the appropriate level.Mobile eye units, covering areas in which nomadic people lived, even deployed drivers as the first point in the referral chain, undertaking simple visual acuity tests.

In the late 1980s, Sight Savers tried to export the idea of training cataract surgeons to West Africa.

Despite opposition from ophthalmologists in some parts of West Africa, the idea has now become widespread. It has enabled ophthalmologists to specialise in areas of most interest to them and acquire new skills in supervising eye-care teams working in the community. Patients have benefited by gaining access to services they would otherwise have been denied, and having problems diagnosed earlier. Sadly, millions of people in Africa still receive nothing, but thousands can now see as a result of this initiative.

In the UK, the medical profession is under immense pressure, but can resist changes that are seen as a challenge to professional status and that it fears may compromise quality. Clearly, patient quality is paramount, but patients are more interested in what is done than who does it. They might like all their demands met by a doctor on every corner and a specialist in every street, but they know that is unrealistic.

They want to see someone who inspires their confidence and, with chronic conditions in particular, 'expert' patients want someone who knows more about their condition than they do.

Over the next decade, patient demand will continue to increase faster than we can recruit doctors - even if we could afford them.We need to re-define who does what, based on an assessment of who is likely to be available to deliver it.We need more doctors, but they need to take on different roles to meet the inevitable rise in demand and to oversee quality across healthcare systems. Role change cannot be allowed to compromise quality and need to be accompanied by investment in training, quality assurance systems and appropriate accreditation to guarantee quality and maintain patient confidence.

However, even with the current system research into patients with chronic conditions shows how far we have to go in delivering quality services, especially in primary care.As demand rises, doing more of the same is not a solution. Creative thinking could reduce the need for doctors to see many patients with minor ailments.

Then they could spend longer with those who really need their skills. To date, the NHS has only just begun to develop this thinking in a serious way, presumably to avoid taking on already bruised doctors, and because the system too often prevents it.

Some forward-thinking doctors are leading the way.

Perhaps the idea of the referral chain, where noone up the chain does anything that someone further down can do, has relevance to the efficient delivery of first-world medicine - as it has relevance to third-world medicine.With funding, proper quality assurance and supervision, this need not be a compromise.We are fortunate in having vast resources for healthcare relative to third-world nations.We can afford higher levels of training and more comprehensive services, but this should not prevent more imaginative solutions.

Referral chains can enrich everyone's job. The start of the chain is the patient, and we should not ignore the potential for self-care to achieve positive outcome.Who knows? Creative thinking about who does what might even give the British Medical Association its 15-minute consultations.

Paul Streets is chief executive, Diabetes UK and a member of the NHS modernisation board