Role substitution: a reactionary approach to health care change

To the Editor: The juxtaposition of articles by Braithwaite and colleagues1 and Ho and Maddern2 (a description of a trial of physician assistants [PAs] in Adelaide) provides an interesting contrast between what should be happening in health care and what is happening.

While Braithwaite and colleagues argue for a value-driven change, the type of change that is occurring at the moment is that of role substitution. This is exemplified by Ho and Maddern’s assertion that “PAs ... would ... improve the quality and quantity of medical service”. The intent is to provide a substitute doctor.

This is referred to as “task” substitution or transference, with the inference that those under discussion, whether PAs or nurse practitioners (NPs), will only perform a limited role — some of the tasks of a doctor. In South Australia, PAs are able to order investigations and prescribe.

The former editor of this journal, Martin Van Der Weyden, discussed this issue in 2008,3 labelling it “doctor displacement”, a term that Brooks and Mitchell disputed.4 They said “[PAs] will never be able to practise independently; they will always have to practise under supervision and within the scope of practice of their supervisor”.

The Health Legislation Amendment (Midwives and Nurse Practitioners) Act 2010 (Cwlth), however, provided NPs with access to the Pharmaceutical Benefits Scheme and the ability to prescribe. Any supervision by doctors seems nominal, with independent practices being set up, some attached to pharmacies. There is less supervision of NPs by the medical profession than that given to trainees in teaching hospitals, and they are effectively independent practitioners. It could be argued that United States-trained PAs are even better trained than Australian-trained NPs, and Brooks and Mitchell’s statement that they will “never” practise alone is hardly reassuring.

Proponents of NPs and PAs justify their use4 by reference to a shortage of health professionals. It isn’t reasonable to take from one area of need (nursing) to bolster another area of need (medicine), and the rapid increase in medical undergraduates and increase in immigration of overseas-trained doctors renders medical workforce projections unreliable.

Role substitution by PAs and NPs will only perpetuate the problems we now face, while introducing new problems related to limited training and skills and fragmentation of care. Australian GPs, traditionally well trained and highly skilled, and with the ability to manage complex problems, are the core of our health system. Proposed changes devalue their contribution by making the inevitably fatal assumption that the sick patient is easy to recognise and triage.