title: Skill mix, doctors and nurses: substitution or diversification?
abstract: This commentary surveys the current arguments for and against modifying the work of doctors and nurses by placing the main viewpoints - substitution and diversification - within the policy background, particularly that of the UK. We discuss the forces for modification: cost effectiveness, professional development, quality improvement and pragmatic management and how each provides a stand-point for evaluation of the issues. Policy makers and managers in the health sector should be aware of the rather fragmented evidence base for doctor-nurse substitution and should consider skill mix changes only when they are clear about: purpose, evidence base, acceptable risks, accountability and quality assurance. Doctor-nurse substitution is not necessarily cost effective, nor is it unfailingly a gain in nurse professionalism or in quality of care. Of the management perspectives available - advocacy, skepticism or pragmatism - the current evidence and policy base favours pragmatism over evaluations of the rightness or wrongness of a general policy.
authors.affiliation: University of Leeds, Leeds, UK.
authors.forename: Lindsey
authors.initials: L
authors.lastname: Banham
authors.forename: Jim
authors.initials: J
authors.lastname: Connelly
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence; D005069:Evaluation Studies as Topic; D006801:Humans; D007318:Inservice Training; D009722:Nurse Practitioners / Q000523:psychology / Q000592:standards*; D010561:Personnel Staffing and Scheduling; D010820:Physicians / Q000523:psychology / Q000592:standards*; D011050:Policy Making; D013222:State Medicine / Q000458:organization & administration*; D006113:United Kingdom