Dr Phil Hammond, GP and broadcaster


   

As I get older, I find it harder to tell where a nurse ends and a doctor begins.

When I was a house officer, we did the curing or killing (itÍs a fine line in medicine) and nurses did the caring. If you were lucky, theyÍd make you a nice cup of tea. If you were desperate, youÍd make them one. And if you were very unlucky theyÍd phone you up at 3 oÍclock in the morning and ask you to write up paracetamol for a patient who was asleep.

Now – shock horror – there are nurses who can prescribe paracetamol without first clearing it with a doctor. There arenÍt many of them, mind, but the very notion that experienced professionals can dish out a tablet sold in thousands of corner shops across the land represents a giant leap forward for the nursing establishment.

This, of course, is only the tip of the iceberg. There are also nurses who sew wounds in casualty, plaster broken limbs, intubate tiny babies, manage intensive care units, pronounce death, set up drips for cancer sufferers, give intravenous injections, run asthma and diabetes clinics and do all manner of things that were traditionally the domain of doctors.

Last week I drove past a hospital that had a sign saying: Warning – Guard Dogs Operating On This Site plastered across the entrance. I can only assume theyÍd run out of nurses.

Now, even the BMA chairman Ian Bogle has seen the light and suggested that nurses take on the key gatekeeping role of GPs.

Yes, itÍll take away doctorsÍ power and skills and further erode continuity of care, but if the Government insists that every patient is given an appointment within 48 hours (whether they need one or not), what alternative is there?

And letÍs face it, many of the problems that surface in your average surgery are self-limiting or psychosocial – so why not let the nurses take the strain, and just take the doctor away from form filling when something unusual crops up?

The killer question is this: Is there anything a good GP does that a good nurse couldnÍt do just as well – and for less?

To minimise any sexual bias, I asked a female GP who works with lots of practice nurses for her opinion. In theory, the answerÍs yes. In practice, nurses are slower (i.e. more careful) than doctors, theyÍre not as good at handling uncertainty and they donÍt like the buck stopping with them.

These problems might be ironed out with training, but then theyÍd be doing essentially the same job as us and, quite rightly, theyÍd demand the same pay. So whereÍs the saving?

Some academics have called for a merger of medical and nursing training, not just because of the job similarities, but so that we could iron out prejudices at an early stage and learn from each otherÍs roles.

It could be a disaster. WeÍd end up with nurses who drink 10 pints. And doctors would have to go on a 3-week course to get a shiny badge before they could so much as open their mouths on the ward.

These cultural stereotypes – of hard-drinking, gung-ho doctors doing operations theyÍve never even seen before, textbook open on the operating table, and timid nurses who arenÍt allowed to so much as breathe on the ward – are very deep rooted. Hence many doctors are still passing off their arrogant incompetence onto patients, and many nurses still havenÍt crossed the paracetamol barrier.

Nurses often cite problems in getting insurance and fear of litigation as the reasons for not openly challenging surgeons for a place in the hospital league table. But in the USA, the most litigious country of all, nurses give anaesthetics, cut chests open and play God as much as the next doctor. Can you tell whoÍs a doctor and whoÍs a nurse in ER?

And in the UK, elderly patients on wards staffed entirely by nurses often do better than on wards where doctors poke their noses in.

So set the gatekeeping nurses free, I say. But be warned – they wonÍt come cheap.

Guidelines in Practice, April 2002, Volume 5(4)
© 2002 MGP Ltd
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