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. 2002 Jul 20;325(7356):165.

Nurses as NHS gatekeepers

Nurses tend to use social rather than medical model of care

Annabelle L Mark 1
PMCID: PMC1123682  PMID: 12130619

Editor—The BMA's suggestion that nurses might act as gatekeepers1 is not supported by the evidence from a three year study of NHS Direct West London linked to a cooperative population of 0.9m.2

Although the computer triage based on the medical model is intended to manage and control demand, evidence suggests that when nurses stopped being employed by the cooperative and became employees of NHS Direct, general practice referral patterns changed considerably. In particular, requests for visits by a general practitioner have now been transposed into the less costly requests for telephone advice from mobile visiting doctors. The nurses moved from being gatekeepers to being patient advocates, using a social rather than the more limited medical model of care. This greater sensitivity may also be why patients like talking to nurses.

The work by MORI, which performed the survey leading to the suggestion, is pointless if patients' attitudes were not surveyed at different points in the need continuum, as attitudes to health access change from the well to the ill.

Lastly, the BMA's proposal should surely have been in a joint report with the Royal College of Nursing if role boundaries are to be renegotiated in this way, especially if it has any chance of maintaining credibility with the public.

References

  • 1.Dyer O. BMA says nurses could become NHS gatekeepers. BMJ. 2002;324:565. . (9 March.) [Google Scholar]
  • 2.Mark AL, Shepherd IDH. Don't shoot the messenger—an evaluation of the transition from HARMONI to NHS Direct in west London. London: Middlesex University Business School; 2001. [Google Scholar]
BMJ. 2002 Jul 20;325(7356):165.

Using nurses might influence developing countries

Anthony Lwegaba 1

Editor—I found the BMA's proposal that nurses could become NHS gatekeepers interesting.1-1 I come from a developing country where nurses and other staff (in some cases minimally trained on the job) are the mainstay of a health system that can afford few doctors.

The trend in several countries, such as Sudan, Somalia, and Barbados, has been to reduce the clinical duties of nurses and auxiliary workers. From my observations this reduction seems to be proportional to the countries' fortunes. This implies that people ask for the best available within the means. In Sudan I was the only doctor to a community of 85 000 spread out in villages over about 80 km2.

A technological knowledge base demands highly trained staff. In a society with high demands gatekeeping requires basic skills in clinical diagnosis. It should also be supported by the communication and technology that can give prompt answers and aid decisions on whether to refer or request investigations or treatment, etc.

The proposal will be a blessing if it works. Besides being cost effective it might halt the trend to reduce the clinical role of staff and strengthen primary health care in developing countries, which tend to copy developed countries.

References

  • 1-1.Dyer O. BMA says nurses could become NHS gatekeepers. BMJ. 2002;324:565. . (9 March.) [Google Scholar]

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