Quacktitioner Alert (13)

In the BritMeds below, I refer to an article by a student mental health nurse who is training to be a quacktitioner and so, predictably enough, does not agree with the views held by many doctors about the role of nurse-quacktitioners in the NHS.

The article deserves consideration for it demonstrates better than Dr Rant or I can demonstrate, the lack of insight that nurses, particularly putative nurse specialists, have about the boundaries of their knowledge and the real role of doctors.

Hang the nurse specialists

Let’s talk about a hot topic that has strong opinions in the medical/health blogosphere: nurse specialists.

The current array of advanced nursing roles - clinical nurse specialists, nurse practitioners, consultant nurses - are a frequent target of Dr Crippen aka NHS Blog Doctor. He accuses them of replacing doctors, of “dumbing down” healthcare, of taking nurses away from patient care, pretty much of being representative of just about everything that’s wrong with the NHS.

Not quite. Replacing doctors and “dumbing down” most certainly. Taking nurses away from patient care, most certainly. But I do not suggest that it is the nurse specialists who are representative of all the ills of the NHS. It is the “dumbing down” that it is the problem. I am equally critical of GPs who rename themselves as GPsWIs and fart-arse around as ersatz consultants, leaving their own patients in the hands of the under-skilled nurse practitioners.

The managerial incompetence and profligate waste of money, and the multitudinous problems in the NHS, have nothing to do with nurse specialists and I have never suggested that they do. The nurses who remain in nursing caring for patients, and would I guess have to be called “nurse nurse specialists”, are the bedrock of the NHS. There is no better example of these than the district nurses. "Nurse nurse specialists" are undervalued, underpaid and abused.

His opinion matters, because he’s the most popular British medical blogger out there. His castigation of the “nurse quacktitioners” has been echoed by other blogging doctors, such as Shiny Happy Person and Dr Rant.

No, you are wrong. Both SHP and the Dr Rant team are independent and strong minded professionals who reach their own conclusions. The fact that we broadly agree does not mean we are echoing each other.

So, nurse specialists and nurse practitioners. They’re useless, they’re destroying the NHS and all doctors hate their guts. Right?

Wrong. They are not useless. They are not single handedly destroying the NHS, and doctors do not hate them. Most of them are well meaning, but have been overpromoted into positions in which they are out of their depth. They flounder around with their clip boards and protocols making tits of themselves.

I refer frequently to my old friends Sue and Dave, though we have not met them for a while. Regular readers will remember that Sue and Dave produced a document explaining how NHS hospitals would be better run at night by nurses rather than doctors. Pause a while to re-read the most delicious piece of bureaucratic botty-wipe that they produced in "Getting a picture of night with Sue and Dave"

Nurse specialists are not medically trained and cannot replace people who are. Those people are called doctors.

You don’t currently see all that many of these roles in psychiatry (though there seems to be an increasing amount of nurse therapists delivering CBT interventions) so I took advantage of a sojourn over to the world of “proper” medicine and nursing to find out more.

Well, you have CPNs who are nurse specialists with autonomous roles that complement doctors. They are very helpful. They are not psychiatrists, and do not pretend to be. However, what we do have in mental health now is the CMHT which is composed of a collection of people, most of whom are not even trained nurses never mind trained doctors and are destroying British psychiatric care. They are cheap though.

On the ward where I’m currently placed, we have a number of patients with a diagnosis of epilepsy. The local epilepsy unit was holding an open day, so I decided to ask if I could pop over to their open day and increase my epilepsy knowledge. The ward manager readily agreed, asking me to “grab any leaflets that they’re giving out, in case they’ll be any use for us on the ward.”

So, I head over to the epilepsy unit. I grab leaflets, I scrounge free tea and biscuits, I go “oooh” at the technological wonders of the EEG (what can I say? I’m a techno-geek, and you don’t get to see much fancy technology in psychiatry. An X-Box for the ward is about as hi-tech as we get). A consultant neurologist is giving a talk on the subject of “living with epilepsy”, so I decide to sit in on his talk.

During the talk, we see a video dramatisation of a consultation between a patient with epilepsy and the consultant neurologist. At one point in the video, the consultation tells the patient, “I can see you’ve got a lot of ongoing concerns, so I’m going to book you in for an appointment with the nurse specialist.” Aha! Nurse specialists! Useless amateurs, the lot of them! Though I can’t help noticing that in the video he doesn’t appear to be seething and gritting his teeth as he says it. Maybe he’s just not a very good actor.

So sweet, and so naïve. Like all putative nurse-specialists, you think that a short lecture with a pot of tea and a plate of Bourbon biscuits can make a silk purse out of a sow’s ear. Or a doctor out of a nurse.

During the question-and-answer session, I ask him, “I noticed that you referred the patient to a nurse specialist. Could you tell us more about how the workload is divided between the doctor and the nurse specialist? Who does what?”

“Well”, he replies, “The nurse specialists add value to our service by providing an extra level of continuity. They give advice and counsel the patients about their concerns to do with epilepsy. They answer phone and e-mail queries. Increasingly they prescribe - not in terms of starting people on new medications, but things like adjusting the doses up and down. When delegating tasks to a nurse specialist, I take account of their level of skills and experience. For example, we’re lucky in that we have a nurse specialist who’s worked here for 15 years. Obviously you just can’t buy 15 years of experience in epilepsy, and she’s very knowledgable on the subject. If she were to leave and be replaced by someone starting from scratch, then obviously that person wouldn’t have the same skills and I wouldn’t delegate the same tasks. The nurses don’t do things like diagnosing epilepsy or starting new treatments - I do that.”

What’s your point, mental nurse?

This poor neurologist no longer has experienced junior hospital doctors on his firm and so has to make use of nursy. She has been around for a few years and he is prepared to let her alter the dose of drugs. By the way, that IS prescribing. And he takes responsibility for what she does. And note, she has been there for a mere 15 years but in that time has not learnt how to diagnose epilepsy.

She is not clever enough to do that. She has not been to medical school. She was probably not clever enough to do that either.

Have some more Bourbon biscuits.

Well, that actually sounds rather sensible, to be honest. It also provides a good repost to Dr Crippen’s argument that all the nurse specialists should be sent back to the wards to do bedside care, because that’s where their skills lie.

Crap.

It is helpful for the neurologist to have nursy around to pat the pateint's hand and fiddle with the dose of drugs, but she is only there because she is cheaper than the doctors who used to be there. She is of value in terms of providing general support for the patient but currently, when patients are dying of bed sores and starving to death due to lack of nursing care, yes, she would be better back on the wards doing some nursing.

I’m not trying to deny that good quality bedside nursing care is vital and is a skilled role, but if you have a nurse who has spent 15 years working and training in epilepsy, then it strikes me as nonsensical to suggest that she should get out of the epilepsy clinic and go pick up a bedpan.

Agreed. She should never have done the 15 years pretending to be a doctor in the first place. Think of all the bedpans she could have emptied in that time.

After the talk, I’m scrounging more tea and biscuits, and I bump into the neurologist. He asks me if I’d had an appointment with a nurse specialist and that was why I was asking.

Heavens, more tea and biscuits; you must have turned into a senior nurse specialist by now.

No, I’m a student nurse,” I reply. “I was just curious as to what her role was.”

“Well,” he says, “We definitely need more nurse specialists, especially in primary care. Because continuity of care is currently lacking, and the nurse specialists provide that continuity.”

Crap. The continuity of care in the community is provided by the family doctors. Remember us? We are the ones who went to medical school and are trained in diagnosis and prescribing. These peripatetic nurse specialists wandering around the community are an absolute liability.

Then he wanders off to mingle some more, while I suddenly develop mental images of Dr Crippen, Dr Rant et al collectively developing an acute case of Exploding Spleen Syndrome at his words.

Yes, we will. Because we see the standard of UK medicine going down the tubes as people with neither the training nor the intelligence take over jobs that need to be done by doctors. And still are done by doctors in the private sector

While we’re on the subject of nurse specialists, mind if I lay to bed a certain myth that I keep hearing repeated on medical blogs. Time and again, I come across people (usually doctors) commenting that “nurse specialists are cheapo doctors for the NHS. That’s why you don’t get them in the private sector.” Dr Crippen has repeated this myth.

Nurse specialists are not “cheap doctors”. They are just cheap.

“The NHS lung cancer patient gets his hand patted by the “lung cancer nurse specialist. The private patient gets Tarceva.…The poor folk can be educated in the comprehensive schools by teaching assistants, and have their health needs catered for by nurse-practitioners and health-care assistants. The rich will continue to pay for public schools and for medical advice from doctors." (Dr Crippen)

Simply untrue. For the record, nurse specialists are not just found in the NHS. The private sector uses them too. This can be found out easily by simply picking up a copy of the Nursing Standard or Nursing Times and turning to the jobs section. If you can’t find a copy, just google the words “nurse specialist bupa” and see what you get.

You really don’t get it, do you. There is and always has been a role for nurses to work with doctors in the care of patients. The Breast Care nurses are a classical example. They work under the supervision of oncologists and provide an excellent service to patients. But they are not a substitute for doctors and are not used as such.

The same in not the case with lung cancer in the UK which is still badly managed, often by chest physicians who have no interest in lung cancer and quickly hand the patients over to the lung cancer nurse specialists. The hand patting may be plausible but the patients die more quickly than they would in Europe and the USA. But then in Europe and the USA, the patients see oncologists not nurses.

My patients die without Tarceva; sometimes without radiotherapy because there is not enough kit, and sometimes without even the benefit of seeing an oncologist. Until such time as there are enough oncologists, enough linear accelerators and enough Tarceva, you can stick your lung cancer nurse specialists up your arse.

The moral of the tale is this: blogs like Dr Crippen’s might be popular, but at the end of they day they’re still just one man’s opinion, and not necessarily an informed opinion at that.

The moral of the tale is that my blog does of course express my opinion and no one else's.

You are perfectly entitled to disagree, but do not call me uninformed. Remember, whilst you are sitting drinking your tea and eating your Bourbon biscuits, I am out in the real world, looking after my lung cancer patients who die sooner than they should because of second rate care provided by second rate people in a second rate service.

It is stressful taking responsibility for patients dying more quickly than they would if they were rich. (see A Tale of Two Cancers) Dying because their care has been delegated to nurse-specialists. I would not expect you to understand that. You are a nurse, and a student nurse at that. I suspect from your tone that you may one day be a nurse-specialist yourself.

Have another Bourbon biscuit.