some implications for nurses and managers of recent changes to the processing and hearing of medical...

Journal of Nursing Management, 2000, 8, 133–140

Some implications for nurses and managers of recent changes to theprocessing and hearing of medical negligence claims

J. FLETCHER ba, msc, mphil, phd, pgce, mbim, diplaw

Senior Lecturer, Postgraduate Division, School of Nursing, Faculty of Medicine and Health Sciences,University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK

Correspondence fletcher j. (2000) Journal of Nursing Management 8, 133–140J. Fletcher Some implications for nurses and managers of recent changes to the processingFaculty of Medicine and Health and hearing of medical negligence claimsSciencesUniversity of Nottingham Aim This paper considers some possible implications for individual nurses and theirQueen’s Medical Centre managers of moves to delegate tasks formerly undertaken by medical practitioners toNottingham

nurses, in the light of recent changes in the legal process, relating to the funding and theUK

hearing of cases of medical negligence.Background It is suggested that the introduction of a system of conditional fees, underwhich lawyers will only recover their costs if they win cases, may lead to a more specialistapproach to negligence claims and to greater scrutiny of medical evidence. Theimplications of the recent ‘Bolitho’ judgement, when judges for the first time subjectedexpert medical testimony to their own independent analysis, are also explored.Findings It is suggested that in the light of the disparities in the training of medical andnursing personnel and in their disciplinary processes, and in view of the lack of consensusabout what training is necessary for those who will substitute for junior doctors, orrepresent themselves as ‘practitioners’, ‘specialists’, or ‘consultants’, that nurses may inthe future find themselves more directly involved in civil proceedings.

Accepted for publication: 4 October 1999

Introduction who manage the health service have cause to be concernedat how the increasing demands on the health service, inPlus ca change?both short and medium term, are to be met safely from

After a recent, uncharacteristic, period of harmony stretched human, material and physical resources. Thebetween the medical fraternity and whichever party hap- problem is particularly acute for managers and prac-pened to be in government, normal service was resumed titioners given the apparent propensity of too many ofin the course of the 1999 British Medical Association the public to see any accident, mistake, or tragedy as aConference at Belfast, with medical support for strike commercial opportunity.action by junior doctors angry at the lack of progress bygovernment to ease their workloads, and medical criticismof the nurse-operated NHSDirect service. Surprisingly Elements of negligenceperhaps, Mr Blair’s peevish response that no patients

The following sketch is intended to do no more than setwere complaining about the quality of the latter serviceout the basic evidential base upon which the rest of thefailed to draw the obvious response that dead men tell

no tales. But to set flippancy aside both patients and those paper will rest, since it is assumed that all who read this

133© 2000 Blackwell Science Ltd

J. Fletcher

will be as familiar with the general principles of negligence no cracks that would allow contamination. Only someyears later was it made known through the medicalas is the writer: probably more so.

All who purport to oCer a service to the public are literature that it was possible for cracks, invisible to thenaked eye, to exist in such containers. As a result it wasbound by a duty of care which places them under a

special responsibility to discharge their obligations in a held that such an eventuality could not reasonably havebeen foreseen by the anaesthetist at the time that theconsistent and systematic manner, on pain of penalty if

they fail. The obligation was defined in the course of an injection was administered (Roe vs Minister of Health,see Table 1), even though it was widely known about atunlikely action—to determine whether or not ginger beer

poured over ice cream, was rendered unfit for human the time the action was heard.For the most part the liability is tortious, and will incurconsumption by the alleged presence of a decomposed

snail (M’Alister vs Stevenson, see Table 1). In the words such damages as are felt appropriate to restore the injuredparty to the condition that pertained before the oCenceof Lord Atkin, delivering the judgement in that case, the

duty covers: took place, apportioned among all those, includingemployers, found to share liability. On rare occasions, of‘…persons who are so closely and directly aCected

by my act that I ought reasonably to have them in which the notorious Beverley Allitt case is perhaps themost tragic (DoH 1994) the failure to discharge the dutycontemplation as being so aCected when I am

directing my mind to the acts or omissions that are is so profound as to necessitate recourse also to thecriminal justice system.called into question.’ (Rogers 1999).

It must be established that the act or omission causedthe damage alleged and that it was reasonably foreseeable.

Negligence in medical practiceFor example the failure of Dr Banerjee to attend threenight-watchmen who had presented themselves at Concern at the prospect of expensive civil litigation has

led some medical practitioners in the United States toAccident and Emergency, having vomited violently forsome hours, was not subsequently found to have been practice ‘defensive’ medicine, in which care that is most

safe may be provided rather than care that is mostthe cause of the death of one of them (Barnett vs Chelseaand Kensington Hospital Management Committee, see eBcaceous. In recent years judges have shown some

anxiety lest such a practice should establish itself here. InTable 1). It was established in the coroner’s court thatthe presence of arsenic in tea that had been drunk was the United Kingdom three other features are apparent in

relation to cases of medical negligence. First is the con-the precipitating factor. And though Mr Roe was para-lysed as a direct result of an injection contaminated by siderable length of time that it takes to bring most

contested actions to a conclusion. Second is the huge costphenol, administered by an anaesthetist who realized thedangers posed by phenol contamination, his action failed. represented by cumulative awards of damages. It was

recently estimated that the costs of medical litigation willThe anaesthetist had carefully examined the ampoulecontaining the injectant, stored in phenol, and observed increase annually by up to 25% in the immediate future.

(Tingle 1997a) It was also reported in Parliament that thecost to the Department of Health of medical negligenceTable 1actions in 1996–97 amounted to £300 million (TheCases with a significant bearing on medical negligence

Stationery OBce 1998). The final outcome of cases cur-M’Alister (also known as Donoghue) v Stevenson (1932) AC 562rently before the courts will probably exceed £1 Billion,Barnett v Chelsea & Kensington Hospital Management Committee

(1968) 1 All ER 1068 all of which will have to be diverted from patient care.Roe v Minister of Health (1954) 2 QB 66 Third is the care taken by the courts to operate in theWhitehouse v Jordan (1981) 1 All ER 267

light of the reality of medical practice, and with evidentNettleship v Weston (1971) 3 All ER 581Wilsher v Essex Area Health Authority (1987) 3 All ER 871 respect for the medical profession. In the case of theBolam v Frien Hospital Management Committee (1957) 2 All ER 118 unfortunate Mr Roe, touched on earlier, Lord JusticeHotson v East Berkshire Health Authority (1987) 2 WLR 287

Denning made clear that the undoubted benefits to beCrawford v Charing Cross Hospital (1953) The Times, 8 December 1953Sidaway v Bethlem Royal Hospital Governors (1985) 1 All ER 643 expected from medical science could not be separatedMaynard v West Midlands Regional Health Authority (1984) 1 WLR 634 from attendant risks, and that:Bolitho v City & Hackney Health Authority (1998) 3 WLR 1151

‘Doctors, like the rest of us, have to learn byEarly v Newham Health Authority (1994) 5 MLR 214experience; and experience often teaches in a hardRoyal College of Nurses v Department of Health & Social Security

(1981) 1 All ER 545 way. Something goes wrong and shows up a weak-Wilsher v Essex Area Health Authority (1987) 3 All ER 871 ness, and then it is put right…’ (1954, 2 All ER 131).

The same judge made clear in a subsequent case that an(Dimond 1995, Hepple & Matthews 1996)

134 © 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 133–140

Medical negligence claims

error of judgement by a clinician did not necessarily hospital to which he was admitted for care. But, hardthough it is to admit it the situation, while not common-constitute negligence, no matter how severe the conse-

quences (Whitehouse vs Jordan, see Table 1). It has been place, is in no sense unique. Having been admitted tohospital suCering from respiratory diBculties his con-by analogy, following an action that was medical only in

the sense that injury was caused to one of the parties to it dition gave rise to such concern on the part of anexperienced nurse that she bypassed the junior houseman(Nettleship vs Weston, see Table 1), that individuals who

represent themselves as practitioners are expected to func- and alerted Dr Horn, the senior paediatric registrar, whofailed to come to the ward to see him. Over the next fourtion to optimum eCectiveness from the first day of their

appointment, within the scope of their post, but that the hours the nurse made numerous additional requests tothe registrar to attend. The child’s condition deterioratedsame standard of performance is not expected of all levels

of post-holders. A relative novice can mitigate its negligence and he suCered a cardiac arrest leading to serious braindamage. Subsequently, as in the Barnett case summarizedby referring acts or omissions to a more senior and

experienced colleague for an opinion (Wilsher vs Essex earlier, the doctor admitted negligence in not havingattended the boy, but denied that this had caused hisArea Health Authority, see Table 1). The actual standard

expected of those who practise medicine was defined in death. She maintained that the only way that he mighthave been saved was by intubation but was adamant thatthe course of an unsuccessful hearing involving an individ-

ual who had suCered considerable physical injury, including even had she attended the boy she would not haverecommended this procedure. A body of medical opinionthe dislocation of both hips and multiple fractures of the

pelvis, having been subjected to electro-convulsive therapy was presented to support this judgement, and as a resultthe action initially failed in the High Court, and laterwithout anaesthetic, relaxant medication or any restraint

other than a mouth gag (Bolam vs Frien Hospital on Appeal.The case is, however, significant in two importantManagement Committee, see Table 1). Known thereafter

as the ‘Bolam’ test, and repeatedly cited approvingly in respects. It was the first medical negligence case to reachthe House of Lords for a decade (Foster 1998). But ofsubsequent judgements, it specified that a practitioner must

exercise the ‘standard of the ordinary skilled man exercising much greater significance was the apparent redrawing ofthe relationship between judges and medical evidence.and professing to have that special skill’ (Markesinis &

Deakin 1998). In relation to diagnosis (Hotson vs East The consequence of this was not such as to discredit the‘Bolam’ test, so much as to clarify how the medicalBerkshire Health Authority, see Table 1), treatment

(Crawford vs Charing Cross Hospital, see Table 1) or opinion(s) presented would be weighed by judges inreaching their conclusions. In the course of his judgementadvice (Sidaway vs Bethlem Royal Hospital Governors, see

Table 1) the way to establish that such a standard of Lord Brown Wilkinson stated, in language reminiscentof his predecessor in the case of Donoghue vs Stevensontreatment had been delivered was through the demon-

stration that the practice in question accorded with the (3 WLR 1151), that:‘The use of these adjectives ‘responsible’, ‘reason-practice of a respectable body of medical opinion, even if

a contrary body of opinion was cited on behalf of the able’, and ‘respectable’ all show that the court hasto be satisfied that the exponents of the body ofplaintiC (Maynard vs West Midlands Regional Health

Authority, see Table 1). While the courts have exhibited opinion relied upon can demonstrate that suchopinion has a logical basis. In particular involvingsome understandable reluctance to delegate to the medical

profession their authority to determine whether or not cases, as they so often do of the weighing of risksagainst benefits, the judge before accepting a bodynegligence has occurred, and have asserted on occasion

that they could envisage circumstances in which they would of opinion as being responsible, reasonable, orrespectable, will need to be satisfied that, in formingreject a body of medical opinion on the grounds that it

was illogical, the medical opinion has never actually been their views, the experts have directed their mindsto the question of the comparative risks and benefitsindependently scrutinized—until the Bolitho case (Bolitho

vs City and Hackney Health Authority, see Table 1). and have reached a defensible conclusion on thematter.’

The implication of this is clear. Judges have longThe Bolitho judgement

asserted their right to interpret medical opinion presentedin court: in the Bolitho case they actually assumed thatIn one sense the case of Patrick Bolitho is not significant.

It represents an individual tragedy for the boy and his right. The claim failed in the Lords also, not because ofthe weight of medical opinion, but because of its evalu-family, and probably considerable stress and heart-

searching for those responsible for his care and for the ation as defensible by the Law Lords.

135© 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 133–140

J. Fletcher

As a result it was made clear that in some circumstances utilities. The present government’s specific pledge not toraise direct taxation, and the unease at the number ofjudges might in future reject a body of medical opinionindirect tax increases that have been introduced at theon the grounds that it was not defensible, as beingsame time, particularly fuel duties, has reduced its scoperesponsible, reasonable, or respectable. It was stressedto deliver its ambitious pledges in relation to such publicthat such circumstances would be restricted to cases whereservices as education and health, where unacceptablediagnosis or treatment were contested, and would notvariations in quality remain evident. The apparently hugeextend to the disclosure of risk. But if the exponentialsums of money that it has promised to improve the Healthgrowth of the legal procedure of judicial review oCers theService amount, in fact, to increases of less than 5% permost striking example of the judiciary’s expansion of itsannum inclusive of inflation, and despite them seriousperception of its remit, it is not the only one. It wouldproblems remain, as the recent concern at the extent andbe unwise to assume that the new assertive attitude toquality of midwifery services, contained in an unpublishedmedical opinion, and to expert medical witnesses, will bereport to the English National Board (ENB), made plain.exercised as infrequently as was originally suggested inIn the first two annual reports on its work, the Labourthe course of the Bolitho judgement.government conceded that it might take as long as 10years to fulfil the extravagant claims made in the course

Current government policy and clinical practice of the 1997 General Election campaign. The need to avoidunnecessary loss of funding directed at the Health ServicePolicy that bears on the question of medical negligence inas a result of expensive legal actions is said to havethe immediate future originates from a variety of sources:prompted the Secretary of State to circulate a lettermost of them remote from the daily concerns of pre-‘Lawyers out of Hospital: Doctors out of Court’ to majoroccupied nurses and health service managers.hospitals and to remark, in his typically fustian manner,Faced on the one hand by the human resource problemsthat the only time lawyers should be in hospitals in whenresulting from the diBculty in recruiting and retainingthey are on operating tables! (Palmer 1998).doctors in suBcient numbers and European Commission

Meanwhile the process of civil litigation has recentlypressure to reduce the number of hours worked by junior

undergone fundamental, if surreptitious, reform, whichhospital doctors per week (Dowling et al. 1996) and on

bears on the question of medical negligence. With a viewthe other by a determined political/professional campaign

to reducing the length of time taken to resolve contestedby their leaders to enhance the professional status and

claims, and in light of a perception that public moneyearning power of nurses, Health ministers in successive was being wasted, the Woolf Report (HMSO 1996) con-governments have sanctioned limited extensions to the tained radical proposals for the role of courts and judgesrole of certain nurses. Minimal nurse prescribing, some in hearing cases of medical negligence. It also sought tonurse-led clinics, and an increase in the numbers of bear down on the amount of public money passing intopractice nurses or nurse practitioners, examples of all of the possession of lawyers via legal aid. It was originallywhich were rather patronisingly cited in the recent suggested that the number of firms able to support actionspublication ‘Making a DiCerence’ (DoH 1999b), and for negligence from the public purse, under Part IV of thecommended because they either kept patients away from Legal Aid Act 1988, should be severely restricted (Anondoctors or avoided them having to take up an expensive 1998), perhaps to those who had previously operatedhospital beds, have been followed by the establishment eBciently, and were members of the Law Society Medicaland extension of NHSDirect and the promise of nurse Negligence Panel (Tingle 1998a). Other firms might haveconsultant posts, for the most part in order to allow the to undertake actions on the basis of conditional fees, ormore elementary aspects of general practice, or the work ‘no win no fee’ as it is more crudely but graphicallyof junior doctors, to be transferred to nurses, themselves known. Writing more recently, perhaps with the passionin short supply (DoH 1999a). of an advocate rather than the detachment of an academic,

As recent government publications make clear this Foster (1999) lamented the loss of legal aid, and itstrend can be expected to expand in the immediate future replacement by a system of conditional fees, as a means(DoH 1997, 1998) not least because of its positive econ- of producing the wrong result quickly as an antidote toomic implications. The concern of successive Chancellors a full and often over-lengthy investigation.of the Exchequer to restrain public expenditure, in orderto reduce levels of government borrowing and to help the

Implications for practitionerscompetitiveness of the British economy, may eventuallyhave contributed to sustained low levels of inflation: it The new system was not introduced until late April 1999

so it would be premature to be too dogmatic about itshas also had less desirable consequences for the public



strengths and weaknesses. But it is already clear that it Despite an emphasis by NHSE that guidelines need notwill have profound consequences for those who practice be followed slavishly at the expense of individual clinicaland manage health care, and for their employers. At the judgement where circumstances warrant it, there must bemost basic level a new language will have to be learned a risk in the immediate future that formulaic practiceby all involved. ‘PlaintiCs’ will now become ‘Claimants’. may become as entrenched as traditional practice has‘Medical Negligence’ will now become ‘Clinical been in the past. At the very least it is likely that theNegligence’ (Midgley 1999). ‘Pleadings’ will become rhetoric of evidence-based practice may now have to‘Statements of Case’ (Stanton 1999). Of more importance become a more evidential reality, and that the notion ofis the new, mandatory, ‘Pre-Action Protocol for the reflective practice may have to withstand legal scrutiny.Resolution of Clinical Disputes’ process. In a service Furthermore the envisaged reforms to nurse trainingwhose record keeping has not always been exemplary the may have to survive independent scrutiny of their extrava-importance of this is impossible to overstate. All incidents gant claims that training will be strengthened (DoH 1999).which have the potential to lead to actions will have to The further erosion of already low admission standards,be fully recorded at once, and all aspects of the protocol and the reducing of the length of courses of higheraddressed immediately: failure to respond to any points education for some students, in the light of work experi-will be taken to imply acceptance of fault. AsTingle ence validated via National Vocational Qualification prac-(1997a) has pointed out this will require a culture change tical assessments, equivalent at best to A level standard,within healthcare. It will also be bureaucratic and has the and roundly condemned in the recent initial report of thepotential to distract hard pressed clinical staC from their newly established National Skills Council (DfEE 1999) sitdirect work with patients. The presence, at all stages, of ill with the view of the Council of Deans and Heads ofan Alternative Dispute Resolution procedure (Stanton Nursing that the way to higher standards is via graduate1999) may also concern individual practitioners who may entry for nurses (Council of Deans 1998). An increase infear lest their ability to have their acts or omissions the amount of time devoted to practice, and in thevindicated will be compromised by a wish to reach a less contribution to the teaching by practitioners, may not beexpensive compromise out of court, on a ‘no fault’ basis.

felt to contribute to the building up of an evidentialOne vital aspect of the new procedures will be the

knowledge base on which to found safe practice. Inability to demonstrate that acts or omissions accord with

addition the explicit intention of the Department ofthe increasing number of guidelines or protocols that are

Health to take the lead in the development of such higherproliferating (Tingle 1997b, 1998b). Recent advice on this

education courses (DoH 1999) may bring it within thematter by the NHS Executive has revealed an awareness

scope of future action. The combination of such initialof how crucial such documentation may be in legaltraining, patchy continuing professional development, andproceedings, with extended guidance on terminology thatthe rhetoric of self-regulation may or may not be evaluatedconcluded by advising specifically against the use of theas leading to care that is responsible, reasonable, andterm ‘protocol’, in view of its directive nature. In additionrespectable. The adversarial parties to actions for negli-advice was given that the guidelines should be clearlygence may have contradictory views on this.stated, be written by someone of authority, be placed in

But why should they? The preceding comments area context that was unambiguous about those to whomspeculative and may strike a number of readers as tenden-they applied and about the circumstances in which theytious. Recent changes in the nature of the financing ofwould be used, and should be reviewed regularly (NHSEcivil actions underlie the comments. The new regime of1996). At least one case has already been heard involvingconditional funding, which will only provide fees to thosesuch guidelines (Early vs. Newham Health Authority, seewho win their actions for their clients, is thought likelyTable 1). In the same way the work of the newly estab-to lead to an increase in specialization on the part of lawlished National Institute for Clinical Excellence (Rawlinsfirms (Foster 1998), and to their becoming more knowl-1999) may come to be a source of legal as well asedgeable in medical and clinical matters. In itself this isprofessional significance in terms of best practice (Dimondto be desired. After all a panel of approved solicitors was1998), as will ‘The surgeon’s duty of care’, produced inrecently established by the NHS Litigation Authority to1997 by the Senate of Surgery, which embraces all thesafeguard the legal interests of Trusts identified as partiesRoyal Surgical Colleges as well as the specialist surgicalto actions (Tingle 1998b). But few will remain comfortableassociations, and which lays out the doctrine of ‘informedon reading a barrister’s speculation as to whether lawyersconsent’ (Foster 1998). In particular this latter publicationwill in future subject particular clinical practices to theirmay be taken as legally definitive in terms of what

constitutes ‘responsible’ disclosure. own form of audit, to elicit if they can be justified on


J. Fletcher

grounds of ‘clinical result’ (Foster 1998). In this context place by the time of the next General Election, and thatsuch individuals will enjoy the same status as will medicaldead men may indeed have a tale to tell.

The cost of bringing an action to court is considerable. consultants, both underestimates the independence of thejudiciary, and places in some jeopardy both the ‘consult-The awards resulting from a successful action are now

huge, many of them running into millions of pounds. In ants’ themselves and those managers who identify andemploy them, in the event of subsequent civil proceedings.circumstances where lawyers will only be able to recover

their outlay as a result of success in the courts, many It is assumed that the ‘Bolam’ test would apply to themin exactly the same way as it has to medical practitioners,actions may in the future find no one willing, or able to

aCord, to take on the risk of preparatory work. Those and that the courts would have to be satisfied that theirclaims to special knowledge and skills were found defens-actions that are taken up are likely to be prepared and

presented with unprecedented thoroughness. It has already ible on the grounds that the claims were responsible,reasonable and respectable.been suggested that guidelines on clinical practice, and

reports on clinical eCectiveness, are likely to come under In the case of those nurses who are now, or who willin the immediate future, be assuming work formerlycritical scrutiny. So too may the plethora of titles by

which some nurses represent themselves as diCerent from undertaken by medical practitioners the position is par-ticularly unclear. Bearing in mind that judges have nowthe bulk of their colleagues. The paradox between nursing

literature, which distinguishes between doctors who cure indicated that they will determine the defensibility ofmedical evidence, and that lawyers will in the future onlyand nurses who care, and the avidity with which nurses

assume medical titles such as ‘practitioner’, ‘specialist’, be recompensed for their eCorts if they succeed in winningtheir actions, it would be highly surprising if thoseand ‘consultant’ (Fletcher 1997a) oCers grist to a lawyer’s

mill, given the importance to claims of negligence of the pursuing a claim did not attempt to persuade judges, viathe precedent provided by the Wilsher case, that theway in which an individual represents itself or ‘holds

itself out’ as a practitioner. ordinary standard of care expected of a nurse performingprocedures traditionally undertaken by medical prac-It is for those who practice that the concerns are most

real. It has been established that a nurse can undertake a titioners was that of the medic, not a nurse (Furlong &Glover 1998).procedure delegated by a responsible medical practitioner

providing s/he undertakes it under close supervision and In relation to these two occupational groups it is onlynecessary to return to the question of training and tothe overall care of the patient remains in the practitioner’s

hands (Royal College of Nurses vs Department of Health state the obvious diCerences to see the ground that canbe exploited. Entry standards set for those who seekand Social Security, see Table 1). But concerns have been

evident in the medical (Dowling et al. 1996) and nursing admission to medical schools are among the most exactingin higher education: those for nursing diplomates are the(Furlong & Glover 1998) literatures about the blurring of

roles, notwithstanding the government’s recent confidence lowest. Medical courses are longer than nursing courses,and the disparity promises to increase if funding of fourin the enhanced skill levels of some nurses (DoH 1999).

It is likely that a nurse (and employer), who is undertaking year nursing degree courses ceases and students areallowed to complete a diploma in only two, rather thanprimary care tasks for which s/he has not been formally

trained could face litigation in the event of a problem three, years. All medical courses are at degree level, andhave been so for generations. Since the introduction of(Dimond 1998). While no case appears to have been heard

that bore on those claiming special expertise in nursing Project 2000 the majority of nurses have qualified atdiploma level. Prior to that courses were essentially(Furlong & Glover 1998) as ‘practitioners’, ‘specialists’,

or ‘consultants’, this does not mean that there is any practical in focus, rather than academic. The majority ofnurse education takes places outside medical schools, withconsensus about either the degree of expertise needed by

those whose titles might convey the impression that they no shared learning. Even where both groups are educatedin the same institution shared learning is minimal. Thepossess exceptional knowledge and skills, nor the level or

kind of training that would ensure the safety of such practical aspect of medical training is in the hands ofdoctors who themselves received a medical training akinpractitioners (Woods 1997). To give two examples, con-

fusion about what constituted appropriate training for to that being experienced by their students. The practicalexperience of nurse training is in the hands of those, thethose styling themselves as nurse ‘practitioners’ emerged

as a prominent theme in a recent piece of research majority of whom had an entirely diCerent type of trainingand who, according to much research, are disparaging of(Ashburner et al. 1997) and should concern the individuals

and their employers. Furthermore, a political declaration academic training, of those undertaking it, and of thosewho have completed it (Luker 1984, O’Brien 1984, Reidthat every hospital should have a nurse ‘consultant’ in



et al. 1987, Laurent 1991, cited in Fletcher 1997b). Initial nursing literature but also in government publicationsand policy statements. But one consequence of partnershipmedical education has been undertaken within universities

from the outset. That for nurses has moved into higher is shared responsibility, for success and failure in patientcare. Dimond (1998) may well be correct in forecastingeducation only within the last 10 years, and may well

move out of it in the near future (Meerabeau 1999) as is an increase in civil litigation in the aftermath of recentNHS reforms. If so nurses are likely to be much closelyhappening to a similar occupational group—teachers.

A similar contrast is evident if disciplinary and account- involved than they have been in the past.ability processes of the two groups are examined.Medicine has long established internal procedures, admin-

Referencesistered by the General Medical Council (GMC 1995)which cover the delegation of work to nurses, and which, Anon (1998a) Access to justice with conditional fees: a consultationin the wake of the widely publicised tragedies in paediatric paper. Lord Chancellor’s Department, London.coronary surgery in Bristol for example, demonstrated Anon (1998b) The regulation of nurses, midwives and health visitors:

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