Diversifying the skill mix: or paying peanuts and getting monkeys

This is what Alan Maynard, economist, and influence behind much government thinking on the NHS, thinks is the way forward:

"...can patient care be maintained with fewer staff or changes in skill mix?...Expensive GPs replaced by nurse practitioners, for example? Double GP list sizes and reduce the demand for such physicians by half? Expensive registered nurses could be replaced by assistant practitioners. Evidence suggests skill mix changes such as these could be cost effective. However, the potential for skill mix is limited by the power of the craft guilds, especially the royal colleges."*

That's right, the future of the NHS should be half as many GPs (so there would be half as many appointments available), or replacing GPs with nurses, and replacing nurses with kids off the street. Sounds like a recipe for success.

Funnily enough there have been some papers looking at this, by one A Maynard, doesn't look like overwhelming evidence for his plans:

"Twenty-two large studies...strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes"

"An extensive review of published studies where doctors were replaced by other health professions demonstrates considerable scope for alterations in skill mix. However, the studies reported are often dated and have design deficiencies. In health services world-wide there is a policy focus which emphasises the substitution of nurses in particular for doctors. However, this substitution may not be real and increased roles for non-physician personnel may result in service development/enhancement rather than labour substitution. Further study of skill mix changes and whether non-physician personnel are being used as substitutes or complements for doctors is required urgently." 

I must say, my experience of physician's assistants in the US and nurse practitioners in the UK to replace doctors and care assistants to replace ward nurses doesn't incline me to feel positive about the future. Currently the NHS doesn't have enough doctors delivering front line services or enough nurses delivering care on the wards. Diversifying the skill mix is just another way of saying that the magic of 'progress' and 'reform' will make up for cutting front line staff. It won't, no matter how many economists sit on their arses pontificating about how successfully managing minor self limiting ailments means that GP receptionists or your Granny can replace consultant oncologists. And who, at the end of the day, will take the brunt of these cuts, who will be ultimately responsible for what these people do? The handful of properly qualified people who are left, with their professional membership at stake and big lawsuits waiting for them as they desperately try and supervise a million under-qualified drones with no professional stake or commitment to their patient's care.

As a doctor I've spent enough of my life running around after 9-5 nurse practitioners, phlebotomists, ward clerks or whoever** doing the stuff they won't do because they can just wash their hands of it when 5 o'clock (or more likely 3pm) comes around.


* Worth bearing in mind when you hear him talking in the news recently about consultants:

"They don't always keep to their job plans and then get to do the overtime. I think there needs to be much more transparency about consultants' pay.
"The public are just not aware of the sums they can earn. If the data was published it would put pressure on them and reduce some of the figures we are seeing."

Interesting from a man making nearly £50k per year for 12 years from the NHS for chairing the board of the York NHS Hospitals Trust.


** Incidentally, one of the reasons that nurse practitioners are cheaper than junior doctors (a band 6 nurse like a nurse practitioner gets £25,472-34,189; a junior doctor's pay starts at 23,533 and goes up to 31,523 before specialist registrar level; healthcare assistants get £13,653-21,798; band 5 front line nurses get £21,176-27,534)- is that they only work 9-5, so out of hours the ever decreasing number of junior doctors has to cover the stuff the nurse does during the day but with a concomitant reduction in overall numbers to cover the out-of-hours rota and no chance to practice under the supervision of superiors whatever it is the nurse does. Medicine is now no longer 'see one, do one, teach one', it's 'read about one, do one'. That's why people die so much more at night.