A seemingly ill-conceived government proposal has reignited the debate about what separates doctors from nurses.
In April, a proposal to the regulations concerning national guidelines for the master’s degree in advanced clinical general nursing was sent out for consultation (1). This was followed by a proposal to the regulations concerning specialist accreditation for the same occupational group, which states that ‘the education must be analogous to the doctors’ specialisation in general practice’ with ‘advanced knowledge in a number of specialist areas’ (2). The Norwegian Medical Association (NMA) was not invited to take part in the preparatory work on this proposal, and the President of the NMA was one of many who were struck by the lack of demarcation between the work of doctors and nurses (3, 4). The Minister of Health, Bent Høie, subsequently stated that no professional groups had anything to fear and that the new proposals would improve the health service in rural areas (5).
A recent evaluation of the regular general practitioner (GP) scheme shows that the workload of GPs has increased considerably in recent years and that too many work tasks rest on their shoulders (6). Higher competence levels among relevant healthcare personnel could free up some of the GPs’ time and allow them to concentrate on their core tasks. Why then is the proposal causing such a stir?
The introduction of primary healthcare teams is an international trend, and pilot projects are now being carried out in several Norwegian municipalities. However, many GPs are concerned that the introduction of primary healthcare teams and the strengthening of the nursing role are being prioritised over fresh funds for the regular GP scheme. There is also concern that the primary healthcare teams will increase rather than reduce the workload of GPs. In an interview in June, the Minister of Health stated that ‘nurses with specialist accreditation may be able to perform tasks that are currently carried out by doctors’ (7). The results of such a policy can be seen, for example, in Sweden, where nurses replace doctors in sparsely populated areas, and this same dynamic is also found in Canada and New Zealand (4).
In rural areas, the operation of the local emergency clinic is dependent on the GP coverage. A typical consultation at an emergency clinic has three possible outcomes for the patient: return home, hospitalisation or observation by skilled personnel locally. Anyone who has had sole responsibility for a poorly patient knows how difficult the assessment can be. This is particularly true in light of the fact that the decision not to admit a patient requires much more assurance, experience and knowledge than the hospitalisation option. The costs of primary healthcare services in outlying municipalities are likely to be lower if the emergency cover is provided by specialist nurses with a five-year education as opposed to specialist doctors with 12.5 years of education. However, there is reason to believe that, overall, the costs and burden in other parts of the health service, such as hospitals and ambulance services, will increase.
This is particularly true in light of the fact that the decision not to admit a patient requires much more assurance, experience and knowledge than the hospitalisation option
What about the quality of the health services? In its consultation response, the Norwegian Centre for Rural Medicine refers to studies showing that the quality of referrals to a specialist deteriorates (8), more unnecessary skin biopsies are performed (9), the use of diagnostic imaging increases (10) and the number of prescriptions for medicines, including antibiotics, rises (11, 12) when this work is not done by a doctor.
Doctors and nurses have different qualifications and perform complementary tasks. The questions about who should do what goes deeper than status and positions – all the way down to the core of the differences between two professions that have traditionally worked well together. Aspects such as culture, identity and function also come into play. We need to hold on to what is at the heart of our profession as doctors – synthesising information, interpreting it in light of in-depth knowledge of the human body and its environment, making a diagnosis, and initiating treatment where appropriate. These are the core tasks of doctors. It is the doctors whose education has taught them how to do this.
It is difficult to regard the development of recent months as anything other than an unwelcome battle of the professions. Doctors such as myself are having to defend why we are best equipped to make diagnostic assessments. Ultimately, it is the patients who pay the price if tasks and responsibilities in the health service are not optimally distributed. That is why it is essential that we have this debate now. The doctors are not conjuring up the problem, as implied by the Minister of Health (5), they are trying their best to maintain a sense of reality in a minefield of interests and emotions.