Trust me, I'm a physician's asst.

March 2, 2001

Will patients be better served by clinical cross-overs in staff training? Mike Pittilo examines new NHS thinking.

It is not a lack of money that is limiting the effectiveness of the National Health Service, but a shortage of qualified staff. The NHS Plan, which sets out the government's intentions to modernise the NHS, identifies the need for at least 7,500 more consultants, 2,000 more general practitioners, 20,000 more nurses and 6,500 more therapists and other health professionals by 2004. Yearly increases in training places for all health professionals are promised.

At the same time, the health service is looking again at how staff can be better employed to support patients. The focus is on a more holistic approach. A Health Service of All the Talents , a policy document now being implemented, argues that the needs of patients should be central to staff development rather than those of professional tribes. The emphasis is on team work with the view that traditional demarcations between staff have held back services. The document calls for the provision of health services that depend on the skills of staff, not their job titles.

This theme also runs through the NHS Plan. Examples are given where traditional professional boundaries have been challenged and roles extended, as with childbirth services led by midwives. New posts that will take over some of the responsibilities of existing health professionals are also being developed. For example, assistant practitioners in radiography will be trained to take mammograms under the supervision of a radiographer, freeing radiographers for film interpretation, previously the remit of the radiologist. It is hoped that new career opportunities could help alleviate staff shortages by appealing to those who might not have considered a career in healthcare.

A working group on the future healthcare workforce has also produced two radical reports that envisage three groups of staff: specialists - consultants, GPs, specialist healthcare practitioners in nursing or therapy roles and clinical scientists; junior doctors and healthcare practitioners, who will probably embrace much of the current role of junior doctors, nurses, the therapy professions and radiographers; and support staff such as healthcare attendants and trainee healthcare practitioners.

These are radical proposals that have met with resistance from the established professions. There is, however, ministerial pressure to challenge traditional ways of working. One idea being looked at is the post of physician assistant. In the United States, physician assistants have existed for many years, working under the direction of a supervising physician. In many cases, their training takes longer than it takes to qualify as a doctor in this country. In England, the Royal College of Physicians has proposed that healthcare practitioners could be trained through a specially designed two to three-year training programme to take up many of the tasks undertaken by doctors and nurses.

The NHS Plan promises the introduction of a new core curriculum for all NHS staff, including a common foundation programme to make it easier for individuals to switch careers. Precise details are unclear but by 2002, NHS staff will have to show an ability to communicate with patients if they are to qualify.

There is a piecemeal approach to some of the innovative thinking taking place. This year, a new model of nurse education is being piloted within higher education in response to the government's nursing strategy and a report from the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, nursing's governing body. To some extent, these changes reflect mistaken views that nursing has become too academic, but also a consensus that there should be an increased emphasis on practical training to improve clinical skills. The new model introduces a one-year common foundation programme and the requirement that practical experience makes up at least 50 per cent of courses. The Quality Assurance Agency is also developing academic and practitioner standards for healthcare education and training funded by the NHS. This covers health visiting, midwifery and nursing and the professions allied to medicine. Profession-specific standards have been developed as well as a common core framework. These are currently out for national consultation.

The focus is not on developing a core curriculum but on identifying where shared teaching and learning across the professional groups could enhance and enrich study. As training has moved out of hospitals and into higher education institutions, there has been more of an emphasis on interprofess-ional education to promote better team working. The evidence indicates that properly constructed interprofessional education can lead to better delivery of care. It will help health and social care professionals deliver the government's agenda for integrated care in a world where local health and social services work together in one organisation.

But will this radical programme work? There is no doubt that new opportunities exist to look at different ways of working. The education and training consortia that were established in the mid-1990s are to be replaced on April 1 with Workforce Development Confederations. The market approach to care created a high level of competition among higher education institutions and led to NHS contracts for education and training being terminated with serious consequences for some institutions. The language is now about partnership, and higher education will be represented on the confederations. They will be powerful organisations in a position to influence change. Unlike the old consortia, they will have responsibility for doctors and dentists over the millions of pounds spent on NHS training of undergraduate medical and dental students and pre-registration house officers. They will have a key role in future planning of the NHS and social care workforces and will be in a position to influence future healthcare roles.

In addition to this, the legislative frameworks for nursing, midwifery and professions allied to medicine are being changed with the introduction of new governing bodies.

There is clearly an opportunity to look afresh at how the NHS works. The climate is ripe for change, but it is still very difficult to predict what lies ahead. At the moment, the public can be confident that a professional administering physiotherapy or an X-ray is well trained and competent. How will we ensure that, as staff take on new responsibilities and extended roles beyond their specialisations, patients will be protected? Where will responsibility rest when something goes wrong?

No one disagrees that there needs to be better team work among professionals and a seamless delivery of care to patients wherever possible. However, role extension of one professional can result in de-skilling of another. The GP would be less able to help the practice nurse with a difficult cervical smear or venepuncture because these would be always undertaken by the nurse.

Where there is strong evidence to support role extension and blurring of professional boundaries, and where this can be regulated for patient protection, such developments should be encouraged. However, care should be taken in pursuing a mechanistic approach to defining clinical competencies and assuming that those tasks that are easily undertaken by one healthcare professional can easily be transferred to another.

For the time being, I suspect that I will want my worrying mole examined by a dermatologist and my X-ray administered by a radiographer. Across the country, these issues are being debated, albeit involving those with vested interests. We have to look ahead but perhaps it is time for us to draw breath and not rush forward too quickly in case we lose what currently works well.

Mike Pittilo is dean of faculty of health and social sciences at Kingston University and St George's Hospital Medical School (University of London). He is chair of the NHS-Funded QAA Benchmarking Group for NHS-Funded Professions Allied to Medicine.

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