The importance of reducing financial spending in health care is currently gaining momentum and therefore the need for achieving cost effectiveness can never be ignored. The aim of substituting cheaper health care providers for more expensive ones has become an accepted practice, with doctor-nurse substitution receiving most attention. This is caused by the increased workload for general practitioners, encouraged redefinition of roles and concomitantly delegation of doctor’s duties to nurses. The nurses should however be working under the direct delegation and financial control of the provider practice.
According to Kernick (2004), doctor-nurse substitutions require being most adaptable operating at the edge of chaos. The substitution should emphasize on exploring purpose, fostering relationship, and building on the strengths of each partner. To ensure financial implication requires connectivity, openness, and feedback. Kernick (2004) indicated that this type of substitution should revolve around encouraging conservation and creating dialogue power shifts from the traditional hierarchical framework to a relational context with the emancipation of voices that were not previously heard. The most fundamental issue is creating a mutual respect for each profession and an escape from each one’s limited vocabulary of knowledge, skills, and attitudes (Kernick, 2004).
Altering the composition of a workforce by substituting doctors with nurses has been found to be financially effective, especially in nursing but it is difficult to know if it is cost effective because the financial implications of releasing one professional time are complex and not always well understood (Iliffe, 2008). For example reducing the proportion of doctors with a replacement of cheaper healthcare nurses may seem economic but savings may be offset by the need to use incentives to attract the nurses into such a reconfigured team (Iliffe, 2008).
In addition, Iliffe (2008) continues to say that the prospect of managing a small team of nurses may seem more attractive than carrying a large case local of hands-on work, but this satisfaction could be reduced if the assistants are poorly trained of inexperienced, if they stay only a short time in the job because of its difficulties the low pay and the hours. Iliffe (2008) further established that the more expensive option having an experienced, high-grade nurse manage a case load directly might be the more stable arrangement that provides high quality care and produces the most job satisfaction.
Substitution of nurses for doctors has the potential to reduce both the doctors workload and costs but not in all settings. Iliffe (2008) say that the workload for doctors may remain unchanged because nurses are deployed to meet previously unmet need or because nurses generate demand for services where previously there was none. Financial savings from doctor-nurse substitution will depend on the magnitude of salary differences between nurses and doctors which may change according to supply and demand and may also be offset by the lower productivity of nurses.
Studies indicate that there is some evidence to support such an approach of professional substitution which is not necessarily cost effective, or necessarily a source of better care or even for nurses an automation gain in professionalism. Iliffe (2008) also noted that some technologies may have the potential to facilitate substitution of doctors and nurses. For example it is important to note that telephone consultation by nurses appears to reduce the number of surgery contacts and out of hour’s visits by doctors, but its effects on wider service use, safety, and financial implications may be minimal (Iliffe, 2008).
On the other domains such as organizational management of services, doctors and nurses may well be interchangeable. Iliffe (2008) comments that “the differences in professional cultures show through, with nurses being focused more towards ensuring teamwork while doctors fostering more on leadership and delegation” (p. 81). However the boundaries of doctor nurse substitution are not known, there are significant indications for adequate training, assessment and quality control systems if advanced roles for nurses are to be widely introduced. All these are likely to increase financial spending, reduced productivity and increase costs.
The impact of doctor-nurse substitution in primary care can be determined by patient outcomes, process of care and resource utilization including financial implications. Studies show that there are no appreciable differences between doctors and nurses (Campbell, Longbottom & Pooler, 2007). Campbell, Longbottom & Pooler (2007) further indicated that “patient satisfaction was higher with nurse-led care and nurses working in general practice tending to provide longer consultations, to give more information to patients and to recall patients more frequently than doctors” (p. 4). They continue to say that the impact of doctor-nurse substitution on workload and direct costs of care is variable.
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On the other hand, Sturmberg & Martin (2007) say that substituting nurses for doctors in different roles may have several consequences. In organizational context, the process will blur the skill sets between these two distinct professions. Secondly Sturmberg & Martin (2007) say that costs will probably increase and thirdly it can largely compromise care, reducing the opportunities for physicians to know their patients and also limiting the establishment of a doctor-patient relationship. One of the most efficient ways of reducing costs related wrong prescription is to ensure doctor-nurse duo working together in health care other than substituting them.
In conclusion, it is important to understand that as primary care organizations and services develop, the need for high-quality, suitability qualified general practice nurses will continue to grow. This implies that developing a good mix of skills at all levels within the doctors and nurses will be important for the safe delivery of patient care. It will also help health care organizations to reduce costs associated with doctor-nurse substitution.
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