GPs abandon ship
Prodicus has just been to the doctor to find that two nurses are running a “minor illness” clinic. They have a little list of "minor" illnesses they feel competent to treat:
- Sore throat
- Earache
- Colds and Flu...
Now I will give you a little list. A list of, say, three dangerous, possibly even life-threatening conditions that could be behind each “minor” symptom that you mention. That’s the mental card index that diagnosticians flick through every time they see a patient. All nursy can do is reach for the protocol.
I think GPs who employ nurses to do this sort of work should be shot.
Labels: lazy GPs, quacktitioners
38 Comments:
It's good to know these nurses can treat dental infections now that it's so difficult to find an NHS dentist. Do they go to dental school as well as nursing school?
After being shot would you send these GPs to
a) nurse led minor illness clinic
b) A&E
c) a real GP
This is very uncommon. Most nurse led clinics deal with nappy rash and taking smears. certainly not the list quoted there.
Presumably that odious turncoat and all-round prat Simon Fradd would be the GP you had in mind.
Or maybe 'Lord" (Robodoc) Darzi would approve.
Totally agree with you on this one.
Woo, anecdote!
I went in to renew my contraceptive pill that I had been prescribed at my old address. GP took blood pressure, was a little concerned (I always come out a bit er, nervous), so gave me a month and booked me in to see a nurse to check it again.
What I didn't know was that the nurse was going to be prescribing and making the decisions involved. Blood pressure was fine, etc. She didn't want me to go back on my pill because my "BMI is over 25". A GP can make their own judgement on this issue, but a nurse has to follow protocol. So I was switched to the mini-pill.
The issue here that protocol doesn't deal with is that I take anti-convulsants that can be affected by my pill (lamotrigine). A quick call to random GP, and it's all authorised and it's all printed.
Come back to my old area, see a GP, explain and get put straight back on my old pill.
What looks like a straightforward issue that can be done with protocols only sometimes wont be. That's what er, a *GP* is for.
LM
You ARE joking, right? This IS a wind-up? Forget the term 'quack' - this ISN'T quackery. THIS IS THE NHS. THIS IS THE ESTABLISHED HEALTHCARE SYSTEM THAT WE HAVE IN THE UK.
John, we've shared emails before - for the non-initiates - I AM a quack in the NHS. I would NEVER make a diagnosis as I AM NOT A MEDIC.
Please read
http://jonathanhearsey.com/?p=35
and replace CAM for NP.
God - I hope I stay healthy.
JH
...sorry for the plug.
As a lowly pawn of the Belfast Trust (I work in A&E) and well aware of the current insanity of the NHS, I was delighted to discover some rational thought still remains....
I work with several great Emergency Nurse Practioners, but even they have expressed, let us say, surprise at several GP clinic nurse referrals - 'please exclude DVT in this patient with sudden onset calf pain while running' being a memorable example. More worrying is my concern that it is easy enough for medically trained staff to make misdiagnoses at times, but legally it would be indefensible if a nurse missed an MI ('indigestion') or a PE ('hyperventilation').... I have the utmost respect for highly trained nurse specialists such as those dealing in diabetes, DVTs, bronchiectasis, but it takes years of experience to confidently and safely deal with the myriad of complaints listed.
Off topic, Dr C, but if you're into G&S then David Colquhoun's adaptation of "I've got a little list" for purveyors of "wibble" might give you a laugh... and I have just done an HMS Pinafore "First Lord's Song" re-write for celebrity nutritional therapists... which may remind you of one such person in particular.
If we can adapt enough of the G&S oeuvre then perhaps we can have an Alternative Therapy musical. Who knows, perhaps some musical medic might even pen a "non-doctor plays doctor" song.
Stunning.
Wonder why I spent all that time doing my MRCOG when the madwives are doing the high risk deliveries (at home) and the NPs are seeing the gynae problems.
Any news from Helen O'Dell?
No news from Helen O'Dell as yet
I have chased it up.
She must be thinking!
John
I'm not sure I can manage fifty minor ailments, but I'll start a list with these two:
(1) Athlete's foot that won't budge with anything I can buy on my own from Boots.
(2) Vaccinations for foreign travel. ("Foreign travel isn't an ailment," you say? "Tell that the the blood donation people," I reply.)
Flippin' 'eck I am staggered at that list.
I have deep respect for practice nurses as I do too for my GP and all staff at my practice, who I find are skilled and helpful. I accept that either I am easy to please or fortunate, or both, but nontheless I suspect that I am like the majority of patients out there; pretty much happy with the medical services available to me, albeit with minor (and occasionally, more serious) gripes here and there.
I wonder though, if amongst her (and of course it may not just be a "her") protocols for headache, back pain and neck pain she would have picked up on a condition I had many years ago (I was 28 at the time) - well before it became as fashionable as it now is - I called my GP out as I felt really too unwell to travel to the surgery, I had the mother of all headaches, a stiff back and neck and didn't like the daylight in my eyes, oh and felt a little sickly too - to my totally untrained mind it seemed a classic migraine headache, but I wonder if nursey would have been as astute as my GP, who called an ambulance immediately and rushed me into hospital.
For the benefit of the non medics out there (I think Dr C and your colleagues reading have already figured this one) I had acute meningitis and was extremely grateful to my GP for spotting this - would the nurse have I wonder?
Steve
Ok, I was for years an NHS secretary and I KNOW what you're talking about. No offense, but someone needs to tell these people that a nurse is a nurse and a doctor is a doctor.
What next, are they going to do surgery as well?
I understand the concern of wether or not a nurse is sufficiently qualified to deal with some of the conditions associated with the list. But, it is worth noting that A&E nurses provide a triage services for dcotors everyday, by dealing with patients with many similar ailments. I don't think the suggestion here is that the nurses are capable of dealing with all the posible causes of these issues. Rather, that they are competent at triaging which symptoms are a warning sign that must be referred to a doctor, and which symptoms are minor ailments that they can easily deal with. The purpose behind such clinics is to ensure that GP time is spent with those who are really ill, and not the hypercondriacs.
Again, you seem to be claiming Olympian intellectual nay mystical and magical talents from O level bio/chemistry with nobs on.
I'm pretty sure if you could knock out the list and the possibilities the nurses could manage to traverse the knowledge base and the judgment call in all of about 3 hours flat.
Are all GPs as desperate as yourself to preserve their monopoly rights over our health?
You're beginning to resemble a neurotic prairie dog pissing around the perimeter of its territory.
Just do something about stroppy receptionists, slum surgeries, hours of business to suit yourself and an attitude which suggests you lot are most comfortable performing permanent colonscopies on yourselves using your own heads as the instrument of choice.
Tiniebras - triage in A+E is definitative treatment, and no triage nurse will discharge people direct from triage without being seen by either a doctor or (for minor injuries only) an ENP. These practice nurses are discharging people, this is very different.
Anonymous, what a fatuous post. Clearly you understand nothing about the process of diagnosis - its not just collecting a list of symptoms and signs and matching them to the commonest cause. It involves taking the symptoms and signs, and then probing further to look for other warning signs (or their absence), and running this down a long list of potential diagnoses - excluding the serious ones, or planning how to exclude them, before coming to the final diagnosis. This may well be the commonest and less serious one, but this cannot be assumed. This task is what the 'O-level with knobs on' that GPs spend 10+ years training to do. The key thing there is 'training' - although experience is vital, the basic teaching and underpinning knowledge of diseases, disease presentation, pathology etc... needs to be there too. This is why undifferentiated patients should be seen by Doctors.
Sorry if this looks like protectionism, its not - its about being properly trained to do the job you are asked to do.
whoops 'triage in A+E is NOT definitive treatment' -sorry for any confusion.
Oh you tease,
-"Now I will give you a little list. A list of, say, three dangerous, possibly even life-threatening conditions that could be behind each “minor” symptom that you mention." -
please deliver on the promise, not because I'm being snarky or think you can't, just waiting for some poor colleage to get brow beaten by "but NHSBlogDoctor says so too, not just the Daily Wail"
j
John,
The severe "long tail" illnesses that you (quite rightly) state can masquerade as simple illnesses affect <1% of the people presenting to the GP. You pride yourself on identifying that 1% and try to make the argument that the NHS shouldn't allow/encourage NPs/PAs etc. in the GP role because they'll miss these illnesses. What you don't seem to grasp is that the government DOES NOT CARE what happens to that small percentage of people if they can save enough money. Of course they can't admit that so they produce papers that show that nurses' outcomes are the same as GP MDs (-- easy enough in that the "sneaky" diseases are rare enough that you'd have to have untold thousands of patients to show a statistical difference.
It's obvious to me that for good or ill this is part and parcel of a government controlled system and it goes hand in hand with not paying for expensive drugs that only help a small number of people. You seem to place a lot of faith in the possibilities of the NHS if staffed with compassionate philosopher-kings found only in Plato's Republic and surprised at the reality uncovered by giving power to a bureaucracy.
In order to counter the views of some members of our parish it might be a useful piece of research to "mystery shop" a number of GPs using the list.
Anybody prepared to bet that GPs would be on the money all the time.
"In order to counter the views of some members of our parish it might be a useful piece of research to "mystery shop" a number of GPs using the list.
Anybody prepared to bet that GPs would be on the money all the time."
I'd bet that the GPs were on the money more of the time than the Nurses in question...
Of course GPs will not get it right every time, medicine is not infallible. However if you have a disease which, although rare, can present as an apparently benign illness -who do you think is most likely to detect it? Someone who leaned about the rare disease, seen it several times during their training and thinks about the chance of the case in front of them presenting as this - or someone who has lots of experience of seeing the common presentation, and has never seen (a in my experience, rarely contemplates the diagnosis of) the rare disease?
Why does everyone think that, unlike other professions, the training of doctors is unnecessary to doing their job? Doctors are not special individuals, they are simply people with the right training to be doctors - architects, dentists, vets and indeed nurses similarly so. Suggestions that 'X' non-doctor can do the straightforward parts of a doctors job simply displays an ignorance of what is actually going on when a doctor works.
Angry Gasman - what disappoints me about your response (and those of other doctors) is that they are virtually context free.
There is simply no mileage in comparing a nurse to a GP in the sphere of minor illnesses.
GP's are experienced senior doctors with highly developed clinical acumen - their role as gatekeepers to the 'nations health' possibly makes them the most important clinicians in the NHS ?
Personally, I am very grateful for the marvelous service they provide.
But............
Since we have no way to reliably determine if vague symptoms are either:
*a benign self limiting illness, or
*early signs of a dreadful disease (like meningitis)
Then we must assume that EVERYBODY is seriously ill (potentially) until proven otherwise by an experienced enough clinician.
To my mind this sort of mindset explains why:
*ambulance call-outs have DOUBLED (in a decade).
*A&E visit are up by >30% in the last 5 years.
And how many GP consultations do you think take place each year........ go on take a guess ?
Well, Wanless estimates 250 MILLION.
Didn't the original architects of the NHS forecast that the demand on doctors would go DOWN as the health of the population improved ?
Oh, and did I mention the walk in centres, they mop up a further 2.5 million visits, apparently.
Surely we have to accept that health capacity is just like the M25- building another lane does not improve the flow of traffic (very much) it merely attracts more cars.
Some might argue that nurses can help the flow of patients (if we stick with the traffic analogy) so that GPs can devote more time and energy to those that really need it - after all it's not as if there is not a huge population of patients, many elderly, with heart disease, cancer, or respiratory disorders all clamouring for the GPs time.
Of course doctors (and medical training) are necessary, Angry Gasman but nowadays the numbers just don't stack up - you don't need to be a doctor to see that the system is bursting at the seams.
How did we become such a sickly society ?
Further to that, charge nurse, lists like the '50' one exacerbate the problem. Medical attention for sore eyes? Colds? Ordinary headaches? (Etc..) However
Some might argue that nurses can help the flow of patients (if we stick with the traffic analogy) so that GPs can devote more time and energy to those that really need it
trained triage nurses, senior ones (my local A & E has them) yes. But I doubt that's what's happening at the practice in question.
“Trouble is, these well-meaning quacktitioners do not understand the difference between mild symptoms and minor illness and do not have the diagnostic skills to discriminate between minor and major illness”
Can they not ask? I guess you have to ask yourself which system is more likely to miss the 1 in 100 long tail illness that presents as a minor ones.
A) Triage/ treatment by experienced practice nurse who because he/she has longer than the 10 minute slot afforded to most GP’s and is generally less stressed is able to spot when something does not “feel right” or lies out his or her area of expertise and has the case reviewed by a GP. Who because he or she is less burdened by an excessive work load and because he or she has already been alerted to the fact that this may be more than a simple headache, cough or abdominal pain is therefore able to focus his or her expertise where it will do most good.
Or
B) The system we have now where over worked GP’s see an endless procession of minor cases and end up missing the important ones because by the end of the day they are too tired/ stressed/ jaded to care anymore and just want to get home to wrap themselves round a bottle of scotch
@ Steve
“For the benefit of the non medics out there (I think Dr C and your colleagues reading have already figured this one) I had acute meningitis and was extremely grateful to my GP for spotting this - would the nurse have I wonder?”
I think most Nurses would have recognized that this was more than just a simple headache. I certainly did I am not even a general trained nurse.
I tire of reading this endless diatribe against Quacktitioners. Many of us are very well able to take a history, examine the patient, reach a hypothesis, and then treat the patient accordingly.We don't all work to protocols, in fact, some of us use the very same clinical evidence based resources as a GP. We presribe appropriately, refer where necessary and work safely within NMC guidelines. Sometimes we too pick up mistakes made by our GP colleagues, they are purportedly human and fallible. That is the essence of team work, we are supposed to work together for the sake of our patients.
PS I too am aware of Red Flag symptoms, it isnt knowledge wholly owned by Doctors. I wish you would find a local primary care ANP to spend a little clinical time with Dr Crippen, you might change you're mind about us.
PS I realise that prescribe was mistyped before you ridicule my english language
I tire of reading this endless diatribe against Quacktitioners. Many of us are very well able to take a history, examine the patient, reach a hypothesis, and then treat the patient accordingly.We don't all work to protocols, in fact, some of us use the very same clinical evidence based resources as a GP. We presribe appropriately, refer where necessary and work safely within NMC guidelines. Sometimes we too pick up mistakes made by our GP colleagues, they are purportedly human and fallible. That is the essence of team work, we are supposed to work together for the sake of our patients. PS I too am aware of Red Flag symptoms, it isnt knowledge wholly owned by Doctors. I wish you would find a local primary care ANP to spend a little clinical time with Dr Crippen, you might change you're mind about us.
+++++++
thank you for that.
Given that you can do everything that doctors can do, why on earth do we waste money on training the academic cream of our youth to be doctors? What a waste of money. We can take our pick of the 5 GCSE brigade, train them for three years, pay them £25,000 a year and get just a good a service.
Clearly they is nothing a doctor has to offer that an NP cannot offer.
I resign
John
I can cite a good example of how the GP reliance on "nurse diagnosis" can go wrong, in this case without serious complications. District nurse calls to see my father to attend to a minor foot infection, notices that his feet and ankles are swollen and diagnoses gout, without reference to his medical history. GP is called out (not his regular GP who knows that my father is on diuretics which cause swollen ankles and feet) and writes out a prescription for gout medication! How a supposedly intelligent doctor could go along with an uninformed diagnosis like that is unbelievable!
Isn't practicing medicine without a license a crime - or is that just in the USA?
At the amusingly named Woking Community 'Hospital', they do this. I am not sure if the 'Hospital' actually has any doctors. I did go there with conjunctivitis [which doesn't seem to be on Prodicus' list] and they dutifully prescribed some antibiotics.
The nurse did very much convey herself as a doctor.
Alison,
It is illegal under the Medical Act 1983, in the UK, to purport to be a "registered medical practitioner" unless registered with the General Medical Council - i.e. to have completed a primary medical qualification/degree.
The line at which one practises medicine is being conveniently blurred by those desperate to erode the professionalism of doctors.
As John has always maintained, the services of a "registered medical practitioner" will become a luxury for the rich, while the oi palloi will have to lump a "health professional"-led service. "Fuck it, that'll do".
Re:
'What a waste of money. We can take our pick of the 5 GCSE brigade'
Thank you Dr Crippen - 5 GCSE O'levels also.. BSc (IANE/RCN)RGN RM several ENB Certs including family Planning , 18 years in primary care and training to become an extended nurse prescriber. You might seek to demean my professionalism but many of you're colleagues don't share the same opinion.
Yeah I am smartenough to be able to differentiate when I can deal with a patient or refer them onwards , pretty much as you do.
Actully latest figures show a decline in the use of "nurse specialists" (including endoscopists and prescribers) in our area as there have been a number of problems as well as the anticipated cost-saving not appearing.
Sorry to say but the few good extended nurses out there (i.e. the ones that have actually got some worthwhile training) are outnumbers heavily by the "i have been a nurse for X years so i can do what you do" but actually are a bit of a danger.
Anon....is it not a bit of a worry that it's taken you 18 years to get to a level where you can prescribe? Us Juniors must be pretty damn good in just half a decade.
With respect, Dr Chris if there is a concerted attempted to 'erode the professionalism of doctors' I think first of all we have to look the EWDT ?
How many hours have been lost because of this far reaching change in working practice amongst junior doctors ?
The wisdom of forcing newly trained doctors into consultant training so early in their career has also been questioned.
I have already given a few stats on the recent steep upturn in demand.
The silence on this fundamental issue (from medics) remains deafening.
I don't think there is a grand conspiracy theory, certainly not amongst the nurses anyway, just hard working staff (in the main) doing their best to deal the hand they have been played - such as the 250 A&E patients who have to be sorted out within 4hrs every single day.
EWTD is a bit of a joke currently. None of us work our allotted hours, we do sometimes go home on time but usually make up for that by ending up staying late the following day.
I really think the EWTD has gone too far in cutting hours, 48 a week??? That’s not a lot of hours and in a job where experience is everything I hope the problem will be sorted in a year or to and we can find a happy medium between 48 hours and the old crazy system (I think the current 56 hours is actually quite civilized).
I was in a position a couple of years ago where I could not even get to see a nurse, only an auxiliary. I kept telling her I needed to see a qualified nurse because I felt so awful. She thought I did not *look* ill enough and getting a GP appt barely possible these days.
Eventually I was admitted as an emergency for blockage in my bowels. Routine blood tests showed my blood glucose to be 43, yes, forty three mmol.
I was started on insulin immediately. Thankfully they no longer fob me off with unqualified nurses.
Post a Comment
Subscribe to Post Comments [Atom]
Links to this post:
Create a Link
<< Home