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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.