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6 September 1999

How to end the nursing shortage

Eric Cainesargues that we should abolish not just junior doctors but nurses as well

By Eric Caines

In the past month, the Department of Health, in an obvious attempt to make the most of the summer lull in health crises, has been releasing bits and pieces of news about how well its efforts to restock the NHS with nurses have been going. The department’s principal claim is that its decision to increase the proposed number of “super-nurses” (or consultant nurses) to 5,000 has been good for recruitment. Not only, according to the department, has it enthused school leavers to sign up in droves for training, it has also convinced qualified nurses, now bringing up their children or working in other fields, to return to the NHS. I hope these recruits will not be disappointed when they discover that their chances of becoming a £40,000-a-year super-nurse are around 100-1 against. I hope, too, that they will not ask too many questions about what this new cadre of nurses is going to do, since nobody seems as yet to have the faintest idea.

I would also note that, amid all the headlines about returners and new recruits, I saw no figures about how many nurses are still leaving the NHS.

I do not blame ministers for trying to make the most of whatever good news they think they have. But I think the advent of super-nurses raises deeper questions about the NHS and about the hospital workforce and its training. And we can see this if we look at some other items of news about the health service that emerged last month.

For example, at about the same time that ministers were hyping their recruitment successes, the Office of Health Economics released the 11th edition of its Compendium of Health Statistics – a snip at £300. What caught my eye was not the widely reported and unfavourable comparisons between Britain and other EU countries on such matters as coronary heart disease and health spending, but a set of figures showing the numbers of nurses and doctors employed by the NHS at various times since 1951. In that year there were 188,600 nurses and midwives. By 1987 that figure had risen to 514,600. Today there are 373,000, a reduction of more than 150,000 in a little over a decade. Graphically represented, that would give a curve rather like that of the Sugar Loaf Mountain.

The curve for hospital doctors and dentists over the same period, however, would be a straight incline, steepening towards the top. In 1951 there were only 14,777 hospital doctors and dentists. There are now almost five times that number, 66,800, with the greatest increase having occurred over the past decade – exactly the same period in which the nursing workforce has suffered its dramatic decline.

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What accounts for this change in the balance between doctors and nurses? One explanation might be that doctors have been taking clinical work away from nurses. Or perhaps the division of labour between them has remained the same, while nurses have shed many non-clinical duties to ancillary staff, and doctors have taken on increasing workloads, including many new specialities. Or could it simply be that the NHS is chronically short of nurses? Manpower planning for nurses and doctors is carried out separately, and it is possible that economic pressures to reduce overall manpower have bitten far more deeply into the big battalion of nurses than into the smaller medical workforce.

All that is pure speculation, but it does raise questions about the policy that underpins the creation of 5,000 consultant nurse posts. Is it a serious attempt to create additional opportunities for nurses to develop further their clinical skills and to make nursing more attractive as a career? Or is it simply a sleight of hand designed to convince nurses that the government is prepared to put more money into their wage packets (even though 99 per cent will never get a sniff of the extra pay)? With regard to the first supposition, I recall only too clearly that when I suggested, at a nursing conference a year or two ago, that nurses could take over many of the clinical functions of junior doctors, I was told in no uncertain terms by a very senior Royal College of Nursing official that if nurses wanted to do the work of doctors, they would have trained as doctors.

Which brings me to the final and perhaps most significant item of August news. In what some chose to regard as simply a silly-season story, Frank Dobson, the Secretary of State for Health, called last week for abandonment of the term “junior doctor”. It was, he said, a demeaning title for that vast proportion of the medical workforce who are still awaiting consultant status but may have been fully qualified and practising for many years. Further, he argued, it unnecessarily undermined patients’ confidence in the quality of the care they receive in hospital. A “source close to Mr Dobson” then achieved the necessary distancing by saying that the minister realised that the matter was one for the BMA and not the Department of Health.

So why was this particular kite being flown at this particular time? I have long believed that the distinction between nurses and doctors is an artificial one. It should be abandoned in favour of a unified, generic grouping that grades practitioners according to the level of clinical skills they have acquired in the course of whatever training regime they have chosen to follow. Inside hospitals there would simply be clinical staff and support staff. A series of grades would cover the range of clinical duties presently carried out by doctors and nurses. All would enter at the same level and receive similar forms of basic training, after which they could pursue different forms of specialist training. Trainees could leave training for practice at certain approved break points. There would be a requirement for practitioners to work under supervision for particular periods of time and for regular reaccreditation thereafter. Individuals could choose to re-enter training and progress to higher levels of more specialised practice at different stages of their careers.

Such a scheme would give far more structured and flexible opportunities for career progression. It would also eliminate the stultifying and unhealthy hierarchical distinction between a male-dominated medical profession and what is still, in effect, a handmaidenly nursing profession.

Could it be that Dobson’s condemnation of the term “junior doctor” represents the first move towards some such reform of the present, in many ways dysfunctional, system? I hope so, though Dobson would need to be prepared for long and bruising battles with the medical and nursing establishments, which, when the chips are down, can be as intransigent as the NUPEs and COHSEs that caused such mayhem in the health service in the 1960s and 1970s. But it would surely be a battle worth fighting.

The writer is a former personnel director of the NHS

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