Fewer doctors? More nurses? A review of the knowledge base of doctor-nurse substitution

The combination of different skills used to provide particular types of primary and hospital care varies considerably from general practice to general practice and from hospital to hospital. Furthermore, skill mixes are changing rapidly as decision makers attempt both to reduce labour costs and enhance the quality of patient care. The remarkable thing about this experimentation with different types of skill mix is that there is little evaluation of its effectiveness and cost-effectiveness. What is the evidence base about the effectiveness and cost-effectiveness of substituting doctors with nurses? The review of the literature presented here suggests that between 30 and 70 per cent of the tasks performed by doctors could be carried out by nurses. It has also been suggested that 30% of doctors could be replaced by nurses, and it is sown that hundreds of millions of pounds might be saved if skill mix could be altered in this way. How valid is such a conclusion. The evidence base is very small, with most of the studies having significant defects in their design. Furthermore, most of the studies are North American and quite dated (having been undertaken in the 1970s and 1980s). Thus the generalisability of the results of these effectiveness and cost-effectiveness studies to the present day United Kingdom is very limited. Consequently an estimate of the potential savings arising from altering the skill mix must at present remain speculative. In the United States, managed care firms are changing skill mix radically, in particular by developing primary care. The scope for such changes in the NHS may be more limited and can only be identified by appropriate research i.e. prospective trials which compare the costs and effects of alternative skill mix combinations. Without such evaluation there is a risk that the quality of patient care will be reduced in the search for financial economies.