Examination of Witnesses (Questions 440-459)
PROFESSOR BONNIE
SIBBALD, MS
DEBORAH O'DEA,
DR HUGO
MASCIE-TAYLOR
AND MS
ALISON NORMAN
15 JUNE 2006
Q440 Sandra Gidley: We heard from
some people that there is a feeling that specialist nurses and
particularly nursing specialist roles are becoming increasingly
specialised and narrow in focus. Is this a good thing generally?
The other thing that has been put to us is that they often do
not like having to perform the basic nursing skills. The phrase
has been used before, but are nurses too posh to wash these days?
Ms Norman: The challenge for nursing
is that they have got to be able to wash and they have also got
to be able to perform specialist roles in terms of role substitution
for doctors and the needs of patients in the service. I do not
think we can do one or the other; we have to be able to do both.
I would say that it would probably not be the best use of nurses
in developed roles to have them washing patients as well. For
example, I told you about the example of our nurse clinician.
I do not think it would be a good use of her skills to have her
looking after the personal care needs of one of our in-patients.
However, I think that personal care needs in patients are as important.
The trick that we have to pull off is to ensure that within the
nursing workforce you have a proper spectrum and that you value
all the component parts of that. In terms of the point at the
heart of your question, we often get very seduced into discussions
about specialist roles, when we also need to be very concerned
about the support and training for the unqualified staff who are
working alongside the professionally qualified nurse, and maximising
the contribution and the ability of the band 5-staff nurse. You
need those people to be good at managing resources and be optimal
in the range of clinical skills they have got.
Q441 Sandra Gidley: I would like
to challenge your use of the word "unqualified". I think
people working alongside nurses in those roles would feel they
have a qualification of some sort. It may not be a nursing qualification,
but I do not think the word "unqualified" is fair.
Ms Norman: I apologise; I should
have used the word "unregistered"; but equally we are
very fortunate in Manchester; we have benefited from the work
of the strategic health authority in setting up a very excellent
assistant practitioner programme. The key thing for organisations
is that you do not invest in colleagues and train them and support
them to a qualification which is a foundation degree in fact,
for those colleagues in Manchester, and then have them coming
back and doing exactly the same job. You have to enable them to
develop that.
Q442 Sandra Gidley: Professor Sibbald
said when talking about the change in skill mix that it was very
difficult to see that any cost-savings had been achieved because
of the different ways that nurses consumed resources, and that
the evidence base is not there to show cost-saving. With the new
clinical roles, such as medical and surgical care practitioners,
is cost the only option? Are we improving productivity or improving
the service we give to the patient? Has any work been done to
show that it is not just cost, but that we can provide a better
service through skill mix?
Professor Sibbald: In general
practice nurses can add quality to the care, so it is cost-neutral
and they are adding quality. For example, patients tended to rate
their satisfaction with their practitioner more highly when that
practitioner was a nurse as compared to a doctor. Part of the
reason for that, we think, is because nurses were less productive
in offering longer consultations with patients and they were seeing
them more frequently; but that was something that was very much
valued by patients. We also know that nurses tend to give more
information and advice to patients, which is again something they
very much appreciate. We know too that nurses working for example
managing chronic disease clinics in general practice—that
that is a model of care that improves the quality of care for
those patients, compared with the situation where the physician
tried to do that with a routine consultation. Adding quality to
care is something that nurses can do.
Dr Mascie-Taylor: Looking at the
question slightly differently, if you look at the targets that
the NHS has now broadly achieved, if you look at the A&E target,
where the targets that we now have largely met would be the envy
of many Western countries—they have been met because of
changes in the skill mix in part. A bit depends on what you regard
as evidence, but the NHS would not have responded in the way it
has and increased its capacity to deal with things more rapidly
if it had not entertained many changes in skill mix and many changes
in systems. There is pretty good sense of increased productivity
in that sense. A lot depends on the nature of the evidence you
are looking for.
Professor Sibbald: A pre-requisite
for a skill mix is that you have a large population to serve of
relatively undifferentiated conditions, or at least there is a
high volume of a particular thing; because that is the only situation
in which you can sustain this ever-increasing specialisation and
role differentiation, both among physicians and between physicians
and nurses. That model of care then drives the system towards
having larger, more complex teams, and that means that if you
are not going to expand the volume of care, you are getting fewer
general practices because they have to be bigger and more complex;
and that model of working is not necessarily efficient, let alone
cost-effective for example in rural settings, with low population
densities. The question of whether skill mix can improve productivity
goes inherently to the nature of the patient population you are
serving. I would also add that there are costs that we have not
talked about yet clearly here today, of having larger and more
complex teams. If before you had one, say, general practitioner
that managed all the problems in his or her presenting patients;
and now you have to have the physicians, the receptionists and
three nurses each dealing with a particular kind of chronic disease—cardiovascular,
muscular-skeletal—then you get a problem with the co-ordination
of care. There is a management cost to having larger and more
complex teams that also needs to be considered.
Q443 Sandra Gidley: Do teams need
to be doctor-led? Some of the submissions from doctor organisations
have said that is very important to retain. Are they just defending
their own interests or are they really necessary?
Ms Norman: Where you have a consultant
physician-led service I do not think it is inappropriate for the
doctor to be the team captain. Preferably they do not need to
play all the roles, and many people do not have much problem with
that, but there may be issues where you are spear-heading new
services where there may not be physician involvement and that
is where that kind of approach and attitude can stymie it. In
years gone by in some of the primary care developments, nurse
practitioners for homeless people and things like that, that kind
of attitude did create barriers to those developments.
Dr Mascie-Taylor: This may not
be popular with my colleagues but in a multi-disciplinary team
people should bring to that team their expertise. Somebody in
that team needs to have expertise in leadership but it may or
may not be the doctor.
Sandra Gidley: That is very refreshing.
Q444 Dr Taylor: The European Working
Time Directive, could we have met it without the extended roles
of nurses?
Ms Norman: Absolutely not.
Q445 Dr Taylor: How will we cope
with the 2009 requirements?
Ms Norman: We will have to become
even more clever in terms of the point made by your colleague
about ensuring that as nurses colonise roles previously undertaken
by medical personnel that we do not abandon the important things
that nurses do.
Q446 Dr Taylor: What scope is there
for extending the roles of other people, such as physios, OTs
and MLSOs?
Ms O'Dea: I am fortunate enough
at St Mary's Hospital to be chairing a group with about 15 consultant
medical staff, a group of nurses and some others, to look at how
we are going to maintain the quality and safety of patient care
24 hours a day, 7 days a week, 365 days a year, with all of the
changes that we are going to face in modernising medical careers,
modernising nursing careers, with my own Trust loosing 3,000 hours
of junior doctor time a week by 2009. I would like to agree with
Dr Mascie-Taylor that our local consultants are actually telling
me we are not being radical enough on your thinking. They are
very keen indeed to do this in a multi-disciplinary team-led way
rather than a doctor-led way, and these are consultant themselves.
We are going to ask Professor Michael West, who has done a lot
of the work around the links between multi-disciplinary team working
and reduction in patient mortality, to come along and work with
that group so we understand exactly how to design a workforce
that enhances the use of the multi-disciplinary team. That is
a physician-led request. We have supported those doctors with
a leadership programme to ensure that they had the skills and
access to the work that has been previously done around the creation
of new roles, including the work previously done by the Modernisation
Agency, so that they can define what the need is as a multi-disciplinary
group of very senior professions and they have the skills and
the knowledge to look at what other people have done and say is
that going to fit here or is it not.
Dr Mascie-Taylor: Could you give
us an idea of the sort of extra things physios, for example, could
take on?
Ms O'Dea: In our own Trust we
have some physiotherapy-led clinics and out-patients rather than
having people constantly see orthopaedic surgeons. Those sorts
of things prove very popular. We are beginning to understand the
skills and knowledge that are going to be needed to bridge that
3,000 hours gap, and only after we have done that will we define
from where those skills and knowledge should come, from which
of the professions. Something that both Alison and Hugo said earlier
is you start by looking at what you need to treat the patient.
You put it into a block and say these are the knowledge and skills
we need at this time of the day to ensure we have quality and
safe patient care. You then redesign the roles around those looking
at what other people have done, looking at what the nursing profession,
the physiotherapy profession and the medical profession brings,
and then decide where those roles can only be done by professionals
and where those professionals need some additions to their current
role in order to take this forward.
Professor Sibbald: If the problem
you are trying to address is a medical workforce shortage, then
the obvious solution is to have more doctors. There are other
strategies for doing that and I know this committee has, and will,
consider those things. The reason for me making that point is
as we change skill mix and develop very new roles for nurses and
other health professions, they are not going to go away in the
future when we have an adequate supply of physicians. You need
to think in the long-term about whether the effectiveness, efficiency
and quality added through these changes that we might make for
a short-term need will be sustained into the future. I do not
see a lot of evidence one way or the other about that.
Q447 Dr Taylor: Thank you for that
warning.
Dr Mascie-Taylor: When asking
what is the work to be done, too often there is an assumption
it is work that needs to be done by a specialised doctor, which
is usually not the case. What is the work to be done and who do
we have available to do it, that will drive some change in skill
mix. Finally, a point you made, sometimes for highly complex services
where you do require large teams of technically driven people
you have to be prepared to take hard decisions about centralising
services.
Q448 Chairman: A number of Accident
and Emergency Departments have changed their process so patients
are now seen by a consultant as soon as they arrive in order to
speed up the decision making, and the quality of decision making
is a lot better for that. Does this not show that one of the important
things is where we deploy skills as well as what skills we have?
Would you agree with that? Would any of you think this could go
beyond A&E and into other areas, certainly in the acute sector?
Dr Mascie-Taylor: I think the
crucial thing in A&E is to recognise that doctors in training
should be providing less of the care and be receiving more training.
They are not fully trained and the rate of decision making is
probably too slow. If a decision needs to be made by a doctor,
the consultant is the one best equipped to do it. The specific
of your question is who sees the patient at point of entry to
the department. There are two ways of doing it: either a very
experienced triage nurse or a very experienced doctor. Either
of those will work and neither is right nor wrong. What does not
work is lack of experience or lack of a system which triages patients.
You need the right person in the right system but you do not have
to be dogmatic about what is their background.
Q449 Chairman: Could you extend that
into other areas within your hospital in terms of people with
more experience seeing patients earlier or quicker?
Dr Mascie-Taylor: I do not have
the evidence but my intuition is the more quickly patients are
seen by an experienced member of staff, whatever their background
including doctors, the quicker will be their treatment, the more
appropriate, the better the quality of care, and the more productive
it will be. That is not surprising as it is the same as in any
other walk of life: the experienced professional will do better
quicker.
Q450 Chairman: What might be surprising
is we are actually having this conversation. As far as patients
are concerned, most of them would think they would see the top
people when they are taken into A&E. In some instances they
do, where it is an obvious situation coming out of a motor car
accident or something like that. Otherwise, is this deemed to
be a part of training of doctors as opposed to other things? You
do not see a consultant when you first go into A&E so why
is that?
Dr Mascie-Taylor: It is in part
because of the very varied nature of problems that present at
A&E, many of which can be dealt with by people other than
a consultant, and part by a relative lack of consultants. If we
had the financial and human resource capacity to have every single
patient seen by a consultant as they arrived in A&E, I suspect
what we would see is some increase in quality of care, some increase
in rapidity of care, and a very substantial increase in cost.
Q451 Charlotte Atkins: Professor
Sibbald, we have already heard from you that your research has
shown that using nurses in place of doctors is cost neutral. You
were saying it improved the quality in terms of patient care,
but your research showed that nurses are more likely to refer
patients to hospital. Why is that, and does that mean that patients
are less likely to receive appropriate care if seen by a nurse?
Professor Sibbald: They were not
universally more likely to refer but there were, in a sufficient
numbers of studies, that you got a small effect in that direction.
The short answer to your question is the appropriateness of those
referrals was not investigated so I cannot directly answer your
question. I can indirectly answer it by saying that the health
outcomes for those patients were not altered, either more favourably
or the reverse, through that referral, and the cost of that referral
was taken into consideration in this overall determination that
nurses were cost neutral.
Q452 Charlotte Atkins: Do you think
there will be any impact by GP commissioning on this process?
Professor Sibbald: The most likely
effect of GP commissioning, as it was with fund holding, is some
marginal change in where they direct patients in the acute section
and a big effect in terms of moving services out of hospitals
and into the community, and in particular into their own general
practices where they can provide a wider range of care. Generally
speaking, the way they have expanded service, the range of service
provision and practices, is to hire more specialised nurses to
undertake that work.
Q453 Charlotte Atkins: What proportion
of current primary care work is done by GPs? This is obviously
in view of the fact that their contract has meant fairly substantial
pay rises for GPs. Are they doing less and getting more?
Professor Sibbald: Yes.
Q454 Charlotte Atkins: Do you think
that is justified?
Professor Sibbald: No.
Q455 Charlotte Atkins: I am very
sorry that we do not have one of our members on the committee
here today because he is a GP and I am sure he would have wanted
to come in there.
Professor Sibbald: I can say on
what basis I give that answer. We conduct national surveys of
general practitioners in this country, about 1,000 GPs. We surveyed
the same panel immediately before and immediately after the contract.
We asked them to report their hours of work and their pay. On
average doctors were reporting a £15,000 increase in pay
and a four hour reduction in their working week. We have a panel
of 45 practices where we do detailed investigations of quality
of care and we have been following this panel since 1998. What
we can see is there has been an increase in the quality of care
steadily over this period of time, and the new contract seems
to have added further value to that, so we are getting something
for our money.
Q456 Charlotte Atkins: This extra
four hours they have to play with, I assume they were not donating
that to the work of the local Primary Care Trust?
Professor Sibbald: I do not have
an answer to that.
Q457 Charlotte Atkins: When was your
research done?
Professor Sibbald: The after survey
was conducted in the autumn of last year, and the before in the
spring of 2004.
Q458 Charlotte Atkins: You were saying
you think that with GP commissioning there is going to be more
activity within the community, if not within GP surgeries themselves.
What changes to skill mixes are required when that happens? Obviously
it is emerging, it is happening now, but what are the changes
in skill mix we need to do now to meet that challenge?
Professor Sibbald: This, and the
most recent White Paper reforms as well as the new contract, will
reinforce a trend that has been evident very strongly in general
practice from at least 1990, which is that you are going to get
larger more diverse teams of health professionals. In particular,
you will see greater role differentiation amongst GPs within a
practice, so partners become more specialist in particular areas
at the expense of being generalist in all areas. You will have
more nurses employed in practices, and those nurses will have
more specialised roles than they have had in the past. Pharmacists
are another health profession which plays an increasingly prominent
role in primary care delivery in minor illness management, to
medication review and in repeat prescribing, among other things.
Q459 Charlotte Atkins: Will this
be at the cost of patients not being able to see their GP, which
some patients value?
Professor Sibbald: Yes. That trend
has been evident for a very long time. As the size of the team
increases, the opportunity for patients to see the doctor of their
choice, or indeed the nurse of their choice, declines. That is
widely known to be true and has been shown across Europe in studies.
We know too that patients value continuity of care, so they do
not like that change, but the question is what are they willing
to trade-off for that. Many patients are quite happy, as was suggested
earlier, to see any professional who is competent to deal with
their problem quickly and simply, but the most vulnerable patients
are the ones who most often value continuity. People with serious
and ongoing problems, particularly of a psychological or distressing
nature to them, prefer to see the individual with whom they have
built a relationship. What I cannot say is globally what impact
that will have on the quality of their care, as the evidence base
for that, although extensive, is divided as to whether loss of
continuity has a negative and damaging affect or not.
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