Blurring the roles: where do you draw the line?

Authors: Kathy Oxtoby 

Publication date:  09 May 2012

Doctors, nurses, and pharmacists are increasingly taking on new roles. But is this in the best interests of patients, and where should the line be drawn? Kathy Oxtoby reports

It used to be that every health professional knew their place. But during the past 20 years roles have become blurred, with pharmacists increasingly taking on duties that were the preserve of general practitioners, and nurses being asked to take on the work of doctors. The government wants GPs to commission services, and hospital doctors are taking on managerial roles.

Ian Wilson, deputy chairman of the BMA’s Central Consultants and Specialists Committee, says that more patients are being treated in hospital by people without medical qualifications because junior doctors are working fewer hours as a result of the European Working Time Directive. These extended roles have also come about “in recognition that there are people with different skill sets who can bring something new to help enhance patient care,” he says.

More gatekeepers

The original remit of GPs as gatekeepers responsible for managing patients in primary care has changed as primary care, diagnostics, and management options have expanded. GPs’ roles continue to evolve as a result of the 2012 Health and Social Care Act, which requires that they be responsible for healthcare budgets and commissioning services.

More nurses are working in extended roles and are prescribing and specialising in areas such as care of patients with breast cancer. With public health services at the heart of the latest NHS reforms, nurses and pharmacists are set to play an even greater part in health promotion. And, following the launch of the New Medicines Service in 2011, pharmacists are also looking to improve patients’ adherence to new drugs for long term conditions.

While successive governments have developed health policies that have shaped and changed the roles of doctors, nurses, and pharmacists, some doctors believe that the lines that divide the responsibilities of different healthcare professionals have become too blurred.

Duplication of work

Keith Hopcroft, a GP in Essex, says that the role of pharmacists has become so broad that they are now duplicating the work of doctors by, for example, carrying out the New Medicines Service. “With many medications for long term conditions that I start patients on, a pharmacist will also be talking to them about the side effects,” says Hopcroft. “This leaves me thinking, ‘What on earth do they think GPs do—just throw tablets at people?’ It’s a duplication of effort from pharmacy and can mean patients could be receiving inconsistent messages.”

Richard Vautrey, deputy chairman of the BMA’s General Practitioners Committee, agrees that duplicating services for patients can be a problem. “If, say, a pharmacist is involved in opportunistic screening, while this may be helpful for patients who haven’t recently seen their GP, some may have already had these tests done. It’s important to avoid duplicating unnecessary investigations or treatments,” he says.

Hopcroft emphasises that GPs’ concerns about pharmacists taking on additional roles do not stem from feeling that their territory is being encroached on. “We’re happy if people want to take on work we would otherwise be doing,” he says. Instead he suggests that some GPs are not totally convinced that pharmacists are equipped to take on expanded roles. “Pharmacists are trying to be quasi-doctors, while at the same time they are running a shop. They are trying to be scientific while peddling pseudoscience,” he says.

Nurses taking on specialist roles that offer specific care for, say, stoma or breast cancer patients can excel in their work, Hopcroft believes. But he is sceptical about the many different job titles allotted to many other nurses. “These titles don’t really mean anything and can be confusing for patients,” he says.

Another difficulty with broadening the roles of nurses and other health professionals is that GPs no longer know who is taking responsibility for patients. For example, a GP’s referral to a consultant urologist can result in the patient seeing a urology nurse practitioner first. “This is annoying, as all too often this seems like an extra layer in the referral process and is probably a way of diluting waiting lists,” says Hopcroft.

One of the problems with extended roles is that politicians believe that general practice can be broken down into its component parts and passed on to other people to free up time for GPs, Hopcroft believes. “This shows a lack of understanding about how life works in general practice. You can’t unpick it—everything we do is intertwined. A typical 10 minute GP consultation could involve talking about anything from diabetes to depression. Without GPs, patients would need to see several nurses or pharmacists to deal with all these issues.”

Understanding limitations

Healthcare professionals agree that they should not take on extended roles that entail working beyond their professional boundaries. “Whether you’re a GP with a specialist interest or a nurse with a special area of expertise, you need to know and understand your limitations and not work outside them,” says Vautrey. The danger, he warns, is when these roles have been created purely to make cost savings rather than improve services, which puts healthcare professionals under pressure to practise at a level beyond their expertise.

Although extending roles in healthcare can be problematic and prompt some to challenge their value, many have embraced these career opportunities because they believe they can increase patients’ access and choice, improve care, fill gaps in service provision, and boost job satisfaction.

Mike Hewitson, a board member of the National Pharmacy Association, is frustrated that some pharmacists still have to prove their value to doctors. He says that although there is inevitably duplication in what GPs and pharmacists do, he has found that doing drug use reviews helps patients to take their treatment and is a valuable addition to pharmacy’s role.

“It would be naive of any prescriber to think patients will do exactly as they are told,” he says. “Pharmacists can help patients take drugs appropriately and get the best out of them, which reduces referrals to secondary care.”

Health promotion is another area where pharmacy is easing the workload of doctors, Hewitson believes. Pharmacy’s role includes offering general health advice to patients, such as referring people to smoking cessation or weight management services. “Pharmacy has more contact with people than any other healthcare profession. We’re accessible and experienced and have built relationships with our customers, so we have a key role to play in health promotion,” he says.

Doctors’ reactions to extended roles in nursing have been mixed, says Jane Warner, a practice nurse in Somerset, associate lecturer at the University of Plymouth, and academic tutor for the Foundations in General Practice Nursing programme. “Most appreciate nurses taking on new roles, but there are some who are waiting with bated breath for a nurse prescriber to do something dangerously idiotic,” she says.

Some nurses who are educated to take on expanded roles may be working in areas where they believe they are unable to use their skills, and there is a risk that they will become demotivated in their work, she says. The reason for this is to do with tradition and power and because doctors go through an intense educational programme, she believes. But nurses are not trying to challenge their expertise, she emphasises. “Nurse practitioners are not ‘mini-doctors,’ nor do we want to be,” she says.

Although presenting challenges, expanding the roles of health professionals has many benefits, some doctors believe. Gill Jenkins, a GP in Bristol, says that medicine has evolved to the extent that GPs can no longer do everything. As a result, she says, “Most of us welcome expert advice from pharmacists and nurses in an era where we have developed a team approach and specialisms within every area of medicine.”

Hospital doctors can delegate tasks too

Some hospital doctors also welcome having non-medically qualified people taking on some of their traditional tasks. Graham Cooper, a consultant cardiac surgeon and fellow of the Royal College of Surgeons, says that having surgical care practitioners work in the operating theatre and advanced nurse practitioners on the wards is now embedded within the culture of the Sheffield Teaching Hospitals NHS Foundation Trust, where he works. He says that as well as freeing consultants to carry out more complex procedures, these practitioners understand the ethos of the units they work in. This helps to ensure a standardised level of care and gives a sense of permanency to the team.

When it comes to extending roles in healthcare, Cooper does not consider professional boundaries to be an issue. “It’s about having a team of people delivering care to patients in the most effective way,” he says.

For Richard Marks, a consultant anaesthetist in London, the pre-assessment work carried out by nurses is valuable in that this routine and time consuming job helps doctors manage their workload. “These days, doctors couldn’t cope without nurses doing pre-assessments—our workload would be impossible. If nurses can carry out jobs that were traditionally done by doctors and do them as well, then it’s common sense they should have these roles,” he says.

To help avoid patients being confused about extended roles, healthcare professionals should explain what they do at the beginning of a consultation, suggests Warner. It is also important for those working in healthcare to establish where extended roles begin and end and to communicate with each other about the work they are doing to avoid duplicating patient care, because no matter how blurred these roles become, “ultimately the buck stops with doctors,” says Hopcroft.

Open dialogue

Hewitson is keen that pharmacists should have “an open dialogue” with other healthcare professionals. “What we want is for GPs to understand that there are benefits in using pharmacy as a provider of services—particularly given their new commissioning role.” And although he understands the scepticism from doctors about new roles, he says: “We will all have to adapt and change or we won’t improve and will just end up staying in our comfort zones.”

The need to adapt and change will become more pressing in the future, doctors predict. Jenkins envisages that within the next 20 years there will be specialists within each healthcare profession who will be offering support and advice to patients. But she says that the basic work of GPs and nurses is vital and that its value should not be underestimated.

The typical role of the GP as generalist could disappear altogether. Given the increasing emphasis on public health promotion, Hopcroft fears that GPs could become public health doctors working in primary and secondary prevention, while minor and acute illnesses will be dealt with by pharmacists. “But if this happens,” he says, “we will lose something in general practice, because one of the joys of being a GP is that we know a little bit about everything, and what we do achieves a high level of patient care with great value for money.”

Given the extent to which healthcare roles have changed in recent decades, it is likely that the roles of pharmacists and nurses will look different in the future. “Twenty years ago pharmacy’s function was to supply medicines. Now the profession has a role in helping educate patients about medicines, and there’s so much more we can do, such as helping manage long term conditions,” says Hewitson.

With healthcare roles becoming so blurred, Warner warns that the title of nurse may no longer exist later this century and that those without a medical qualification “could end up being some sort of healthcare facilitator, making patients even more confused about who exactly is treating them.”

These varied predictions about how healthcare might look in the future highlight how uncertain healthcare professionals feel about what they may be expected to do, particularly in the light of the Health and Social Care Act. “We’re all worried about our roles and where the cuts to services will take us, so being a bit protective of what each of us do is entirely reasonable in these challenging times,” says Wilson.

Government changes to healthcare provision may well result in more competition between different service providers. However, as Vautrey says, “We need to support extended roles by working together across organisational boundaries, whether we’re doctors, nurses or pharmacists, for the benefit of patients.”

Competing interests: None declared.

Kathy Oxtoby freelance journalist, London, UK

Cite this as BMJ Careers ; doi: