The Maynard Doctrine: Professions, guilds and silos
Professor Alan Maynard OBE torches a Spaghetti Junction of bridges with the professions. The RCN in particular will be very fond of him for this …
There is a proliferation of professions in healthcare and as George Bernard Shaw emphasised, these institutions are “a conspiracy against the laity”.
There are umpteen Royal Colleges providing some education, good food and wine for members of various crafts, funded in large part by tax breaks. There are seemingly endless guilds supposedly controlling operatives such as nurses, occupational therapists, radiologists, psychologists, physiotherapists.
Then there are trade unions seeking often to protect the incomes of the low-paid, of which there are tens of thousands in the NHS.
A brief history of guilds
The professions grew out of medieval guilds, whose purpose was to ensure patient safety and by controlling entry to the profession, ensure that members’ incomes were kept at a “nice” level.
Over time these professions have joined forces with another medieval institution, called universities and colleges, which increasing make nice incomes from training and educating these professionals.
This “entente cordiale” or mutual feeding frenzy creates a number of problems for any healthcare system.
Firstly, the professions operate in silos - and in order to enhance their incomes, protect their job roles or “turf”. Why can’t physios and occupational therapists carry out nursing roles? Nurses’ primary roles are controlling drug administration, putting up drips, monitoring patient health status, and cleaning and feeding their customers. Why can’t nurses do the tasks of physios and occupational therapists?
’As courses grow longer, institutions of higher education grow richer - but does the quality of healthcare improve? Or does this grade inflation merely lead to inflated wage demands for the taxpayer to fund?‘
One answer to such queries is that such role changes could only be tolerated if the individual took another higher education course, thereby keeping universities and colleges in the style to which they are accustomed.
As courses grow longer, institutions of higher education grow richer - but does the quality of healthcare improve? Or does this grade inflation merely lead to inflated wage demands for the taxpayer to fund?
The standard of living of such institutions is further augmented by grade inflation. Late off the starting blocks as compared to North America and elsewhere, the Royal College of Nurses has persuaded government to make nursing a graduate occupation.
Some may fear that graduate standards may fall given the quality of the intake. Yet even if this were so, why do we need graduates to carry out the usual nursing roles essential for patient wellbeing and recovery?
There is not only a risk the nurses will be “to posh to wash” patients, necessitating the recruitment of expensive support staff. Is any government strong enough to say such recruitment will be a process of substitution rather than inflationary and complementary? The RCN would of course oppose such “dilution” of skills to protect its member’s interests thereby acting in self interest rather than the interests of patients.
Cost inflation as well as grade inflation – just what we need
Furthermore, nurse graduates may expect to be paid more. NHS Generalissimo David Nicholson denied this was his expectation when questioned before the Parliamentary Select Committee on Health. Clearly he is living in cloud cuckoo land on this issue!
Universities and colleges of course welcome this grade inflation: they are paid per student signed up. But this group of guilds might usefully be challenged as to whether they create the skills needed by healthcare workers such as doctors and nurses.
One instance: many undergraduate and graduate courses seem to be “lite” on teaching students set to work in the NHS about how the organisation is funded and provided, and what it is like to work in a financially-constrained, target-orientated and highly regulated structure.
There is no ‘i’ in team (but Apple are working on it)
Another nice area for debate is teamwork. We train NHS graduates, be they doctors, nurses or whatever, to work in their patches or silos. When they get into the NHS, they have to work in multi-disciplinary teams.
The major clients of any developed country’s healthcare system are the elderly. They typically have multiple morbidities, requiring integrated pathways of care covering primary, community, mental health and acute care.
’We train NHS graduates, be they doctors, nurses or whatever, to work in their patches or silos. When they get into the NHS, they have to work in multi-disciplinary teams.‘
Does the need for teamwork not imply the need for some “interdisciplinary” teaching with future team colleagues? (N.B. the word “interdisciplinary” is in inverted commas as few if any medical crafts are based on a discipline, but rather are subjects).
Low-hanging fruit of reforming training
If the new government in May is looking for more efficient use of training and education resources and more appropriate induction of practitioners into working for the NHS to improve patient care, maybe it is time to reform both the provider guilds such as the Royal Colleges and the colleges and universities that “train” them?
A first step might be the introduction of shorter courses.
After all, the University long vacation was designed to let the aristocracy return home and ensure that the peasants collected the harvest efficiently. It may at last be time for the taxpayer to insist that this is no longer necessary.