Not surprising there is a "Turf War" going on! Doctors with elitist attitudes are going to fight like demons to protect their hallowed ground. Often, a nurse or paramedic can do a better job, especially in areas of first aid, minor ailments. Doctors, in my view should be a back-up where the first line of treatment needs are potentially life-threatening or not working.In many cases they are, but nurses should be trusted much more, in my humble view.

Some larger ships of the Royal Australian Navy carry Surgeons who double up as MDs, but most vessels, particularly smaller ones, carry only a Medic, maybe a Para-Med. These personnel have occasionally been called on to even operate on injured and sick personnel, where life is in the balance and the ship out of reach of a surgeon, owing to distance or weather conditions.

It was nurses, meds and para-meds who saved my life on three occasions, with the doctors trying to claim credit afterward, by putting the med on the carpet for over-stepping the mark. Complete twaddle, it seems the doctors would prefer I was dead, than have a nurse save my life - "dead men tell no tales," I guess.

In my military, repatriation and private hospital experience, gained the painfully hard way, over some 27 years as a patient, nurses and meds, para-meds have a lot more of what many doctors lack - common bleeding sense!

Common Sense seems to be a commodity in such short supply in our modern world, as we become more and more "clever" and more and more dependant on a computer and so-called "protocols."

Oh dear, hope I haven't upset too many?

Charles

Charles,
If the truth hurts you may have upset someone, certainly not me. I constantly ask myself why a government with a projected budget surplus of $17 billion, a world wide shortage of doctors, nurses with a university education, don't firstly train more Australian doctors? Secondly have more nurse practioners and thirdly increase both Public Health and Education spending to accomodate more Health and Educational infastructure.

Maybe they are correct, we need a tax cut, that should help us to live a healthy life, an extra $3.50 per week will make all the difference, not! Do you think the AMA may have a role in this, doctor numbers down, price for seeing a doctor up......

There are two turf wars.

There is the one between the federal government and the states over health care funding. Then there is the one between the medical profession and everyone else.

On the former, there have been recent signs of some movement. On the latter, it will be difficult to get action until doctors accept that they are not the hospital system's customers - patients are, or should be.

Do we have a doctor shortage? We certainly have serious maldistribution. But it takes half the time and rather less than half the cost of training a doctor to train a nurse-practitioner who, as Flezzey points out above, can carry out many of the routine duties that are today limited to doctors.

The health care industry operates with more than its fair share of dogma, superstition and politics despite the fact that it is more than 60 years since Dr Archibald Cochrane, interned in a German prison camp, realised that evidence might be helpful in determining effective approaches to health care. Occasionally, if all else fails, doctors are starting to consider evidence.

A recent example that received international recognition was when a group of doctors at Liverpool hospital realised it was more effective to treat patients before they were dead rather than after, http://www.ethics.org.au/ethics_forum/forum_posts.asp?TID=1333

Yesterday two studies were released containing the startling revelation that hospital overcrowding increases patient deaths, http://www.smh.com.au/news/national/doctors-link-deaths-to-crowded-hospitals/2006/03/05/1141493548871.html

We could do with more of this sort of work and policy initiatives that take it into account.

Can we please nuance this argument. There are doctors and then there are doctors.

By and large the fees charged by GPs are governed by the rebate provided for various services by the Federal Government. Within close levels of price sensitivity, GPs simply can't charge much more than the recommended levels. To that extent, they have much less turf to protect and a much greater openness to using practice nurses and even nurse practitioners. Yes, there are exceptions but, by and large, general practice is already in the throes of changing rapidly to team-based care that better utilises the skills of each person.

On the other hand, I think I've ever met 3 or 4 people who ever got a competitive quote from different specialists for a particular operation. By and large, specialists are able to charge what they like with quite massive differentials between various locations based on the demographics and demand. Hence, there was an article in the weekend Tasmanian papers calculating how a Tasmanian specialist could earn a half million dollars a year working half a day a week. It is these specialists with very large turfs to protect who are carrying on about role reallocation.

As evidence, the AMA had released a statement strongly condemning the use of nurse practitioners other than in very restricted circumstances. The ADGP, by contrast, representing general practice has welcomed nurse practitioners and wants them working with general practitioners as soon as possible.

Regards

Kevin

You are correct to some extent Kevin. The acceptance or other wise of role substition or degrees of it varies from group to group- but very few of the doctors unions are overly representative - and while different peak bodies have particular public positions there are dissenters in every group.

But my arguement remains that role substitution has been an evolving process particularly in the public sector. Whether it be physios nurses or OTs all these disciplines have moved into areas that have either been adandoned by doctors who have moved on to other technologies or who have seen it expedient to leave particualr work to other professionals.

Where we are faced with either genuine shortages or maldistribution the old ways of delivering health care are failing the consumer. To simply recognise the real face of the industry and how serviecs are delivered and have been delivered by non medical staff is doing little more than formally recognising a well established defacto form of health delivery.

And doctors are not monolithic on this front - in addition their support for well managed role substition seems to increase in direct proportion to their distance from a major population centre; the more remote they are the more they see and give recognition to the skills of the non medically trained staff who work along side them - they need all the help they can get.

A resolution to this tension will not solve the problem but it certainly needs to be part of the solution

Kym Durance

Kym

Thanks for that very reasoned argument. I accept the premise that no groups are monolithic or united in either their opposition or support. Having said that, just as with the more remote doctors, those who have least to lose will oppose change least as a general rule of thumb. In broad terms, that's GPs and nurses, though even some registered nurses in my local health district are carrying on like 2 bob watches about enrolled nurses taking over "their" work. It would be hilarious if it weren't so sad.

That said, folk in this area recognise that we will either work together to resolve these issues or we will have a major public health crisis on our hands. With many thousands of people flooding in, chronic disease on the rise and a rapidly falling workforce as older doctors and nurses retire, we simply can't continue to work the way we have done in the past. So, for good or ill, and regardless of what politicians and senior bureaucrats think, people on the ground are rapidly finding their own resolution to some of these issues and trialling a range of approaches.

Regards

Kevin

As a patient recovering from surgery I had more confidence in those nurses who had received hospital based training. Learning nursing through simulation exercises is no substitute for the real thing, on the job training, that's where you learn bedside care.

However the old hospital based training system treated the student nurses like skivvies.
How unfair to expect the girls to learn theory by day then supervise a ward by night. yeah, I know boys are nurses now.
Another advantage of the hospital based system was the nurses were paid, poorly, and had accommodation provided - a boon for country and outer suburban girls.
Today's nursing student in Victoria has a HECS debt then will probably do agency work until s/he passes the audition and gains a permanent position at a hospital. I have talked to young nurses who have years of agency work. This employment practice is unappealing.

In fact the extreme hours resident doctors have to work is questionable also, what does it achieve? When you realise the "old man" treating your 68 year old father is a haggard 28 year old resident you wonder whether he really is alert enough to exercise sound judgment.

Kevin - The point made about the same kind of turf war between Div1 and Div 2 nurses is well made and represents another part of the conundrum.

That demarcation dispute has been with us for a long time but the tension has increased over the years as the work force in broad terms has become more skilled - I had a major blue with a DON years ago when I taught SENs to perform ECGs - in her way of thinking it was a task well above their station - but at the end of the day it was a simple mechanical task.

The other problem relates to the ageing of the workforce - while it is all well and good for me to prattle on about nurses and other profesisonals to assume some roles undertaken by medicos we need to face the fact that that work force is ageing and shrinking as well.

Another impediment to skill shortages, for example, is the cost of post graduate training - with a relative crisis in obstetric services particularly in rural areas - RNs who wish to gain reigatration in Midwifery are up for a bucket of money for the education via the Universities either in up front fees or HECs for little finacial return at the end.

So even if there is an incremental shift in roles and responsibilities gaps will stil remain in service provision; some one made the point we do not have a health care system but a disease management system and until more money is put in at the fornt end on disease prevention and health promotion we will remain a long way from a solution.

Kym

Kym,

I agree with all of that.

WA recently had a session where they "educated" a panel of consumers about what the health issues were and what all the various constraints were. Their conclusion - we should spend considerably more on mental health and clear that awy; we should spend considerably more time and resources on preventative healthcare; and we should balance the budget by spending less on hospitals. A whole lot more of course but they were the community's conclusions at the end of even a relatively brief exposition. How much more enthusiasm for change could we harness if we began talking to people openly and honestly about what governments can and can't do and what the community/individuals are responsible for.

Role reallocation ** will ** happen, just as closer integration between private GPs and public hospitals will (and indeed I'm already seeing happening). People's own enlightened self-interest will dictate co-operation between healthcare providers over the near future. What we now need is to start appealing to the community's enlightened (and we need to do the enlightening) self-interest.

Regards

Kevin