Just show us the money

Editor - Two recent articles, one in a national newspaper, and another in the April edition of BMA News gave me cause for alarm recently. Both articles concerning the government's proposals for NHS reform. A highly admirable commitment has been made to the funding of the NHS, but it is the somewhat ridiculous changes that the government is demanding "in exchange" for its fiscal generosity that worry me.

First, the government suggests that health professionals could complete part of their training together on a "medical foundation course". You have only to ask any medic or any nurse about this idea and they will tell you that either student nurses would waste time learning things they didn't need to know, or medical students would waste time on a course that did not impart the depth of knowledge demanded by their future profession. From the very beginning, nursing and medicine are totally different: just compare the two syllabuses.

Second, it is suggesed that traditional professional boundaries should be broken down. There is indeed potential for the extension of the role of a nurse, especially in the realms of common practical procedures and more routine clinical decisions; things that most nurses would be very capable of doing with little or no extra training. Unfortunately, ideas for new career structures that will supposedly allow care assistants to become nurses, and nurses to become doctors miss the point and, frankly, are an insult to the nursing profession. Nursing and medicine are two distinct professions, with complementary, yet completely different roles. Nurses require many of the same basic skills as doctors, including many practical skills, a basic understanding of the clinical aspects of human anatomy and pathophysiology, and a great depth of compassion. Their role is essential, but they are not doctors. Creating super-nurses and physician's assistants posts is, in my opinion, a cheat: I am concerned that they will carry out some of the work of doctors but might not be paid extra for it, just as at the present time care assistants perform the role of nurses, but do not get paid accordingly. Reform of the basic clinical systems risks dumbing down the calibre of NHS staff, with a resultant army of technicians whose narrow field of training will not allow them to adapt to the reality of changing clinical situations, inevitably reducing versatility in the work force.

I think the consensus among the public and healthcare professionals alike would be that our health service does a fantastic job, and that by far the main cause of its rather conspicuous shortcomings is a disgraceful lack of resources. It is surgeons who carry out the thousands of life saving and life improving operations that take place every year, and nurses who look after patients before and after, and it always will be. The proposed new roles will be superfluous to the real task in hand, a dangerous political gimmick to give the illusion of change and modernity. We need more doctors and more nurses. That is the simple answer to our problem.

Underlying the government's proposals, there is an inferred insult to NHS staff. Apparently, the horrendous problems faced by the NHS are not just the fault of lack of funding: they are the result also, it seems, of poor, inefficient practice by doctors and nurses, and of counterproductive stubbornness on the behalf of the medical establishment. What the government doesn't realise is that the NHS is accustomed to tightening its belt: we are probably one of the best value for money health services in the world. Putting more money into the NHS is not money into a black hole; it is investing money into a ruthlessly efficient machine, capable of squeezing every last drop of productivity out of each penny it is given. It seems to me breathtakingly arrogant for New Labour to think its ideas for the health service are better than the system that has been developed over the lifetime of the NHS. Would the Prime Minister consider telling the armed forces how to operate in a war? He should let the people in the know-us and our colleagues in the other health professions-decide how to spend the country's health care budget. Give us the financial freedom Mr Blair, and we will deliver the results.

Tom Caudell, second year medical student, University of Southampton


studentBMJ 2000;08:217-258 July ISSN 0966-6494