I find it disturbing to be in complete agreement with both Dr Cottingham and Dr Fogarty, but in this particular case I am.
Doctors are the most expensive staff members per hour worked in EDs.
Much of what is currently done by doctors in UK EDs could be done by less well trained staff members.
The same could be said of ENPs.
Physical space while an anathema to hospital managers is actually relatively cheap- a 13.5 square meter consulting room (GP surgery size- minors cubicles in EDs are usually smaller) costs around £5 a day by my calculations (plus 50- 100% if you're in a PFI).
It does always strike me that in places with large volumes of minors at certain times of day the most cost effective way of working is likely to be a doctor moving from cubicle to cubicle (a HCA calling patients into the cubicles, helping them on trolleys, helping them get undressed etc.) with one or assistants writing the notes and forms, entering things on computers and communicating with other staff about procedures that need to be done that are within their competence.
A colleague who had worked in an academic surgical department in the US once told me of when he was caught by his department head doing some photocopying and was told "next time I catch you at that I'm putting you on a secretary's salary". In the UK particularly in EDs there seems to be a certain culture of doctors being proud of doing tasks that could be done by someone of below their grade and of other people praising them for doing so. We need to start looking on this as what it is- being paid more than you're worth. Team work is not about everyone mucking in and doing the same thing, it's about using each team member to the best of their ability. If you have doctors regularly putting on dressings, writing up forms and entering data onto computers, you need to reduce your number of doctors and spend the money on cheaper people who can do the job just as well.

>  Because in the eyes of lay managers who have little understanding of
> the realities of clinicla practice or the benefits of rich 
> skill mix the
> requirement is to deliver service with the minimum number and grade of
> staff you can get away with ...

Well, they're making a pretty poor job of it if they are employing ENPs and doctors to do clerical work, simple dressings and moving patients from one part of the department to another.

> The question is will  none medicla staff ever replace Consultants and
> other senior doctros - probably not  but  we will see an 
> increasing move
> away from service provision by the trainign grade  medical staff ...
> The comparision between the a few months I nthe speciality  
> SHO and the
> several years if not decade +  of experience of the senior Nursing
> staff... Vic alludes to this  but sees the regualrisation of 
> thepractice
> he describes as a threat  rather than explicit acknowledgement of the
> practice...

It is certainly true that with Modernising Medical Careers there will not be enough doctors to see current numbers of A and E patients by 2013 or thereabouts. The question is whether the way to deal with this is by reducing numbers or A and E patients (however, bear in mind that in the past various ways have been tried of doing this and none of them have actually reduced numbers in the long term); by use of nurse practitioners or by experienced doctors working with assistants. As Dr Cottingham says or implies, the evidence is not being reviewed; the cost effectiveness research is not being done; and the debate is not taking place.

> what you are
> actually saying is "employ more non-clinical staff and 
> therefore have fewer
> doctors/nurses."
> 
> Why don't you do the sums and put forward a business case for 
> this and see
> what happens?

Such cases tend to be rejected. There is a culture of egalitarianism in hospital management these days that feels that we should be looking more at having new ways of working and medically and non medically qualified people rather than providing as much assistance as possible to our most highly paid staff to increase their productivity.

> Now, of all those steps, the only ones that need a medical 
> qualification 
> in any shape or form are clerking and examining.

Although if you look at the traditional medical clerking, much of that could be done by non medically qualified people; and indeed some of the examining. A way I have heard of (can't quote where, someone on the list must know) is A and E consultants doing a "ward round" of their trolleys area, spending about a minute with each patient and giving a list of what needs to be done- bloods, full neuro exam etc. A certain amount of this could be done by non doctors (again, needs debate as to how much). Certainly with admitted patients inpatient consultants tend to want a full clerking on the ward round. With reduction in junior staff in all specialities a way to do this would be a rapid assessment and initial management plan by the EP; a full clerking by someone else (possibly a role for the ENP here) on stable patients needing admission with or without contacting the EP if anything unexpected turns up.


Matt Dunn
Warwick.



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