Wednesday, 22 June 2011

Acting up

In his latest post, Dr Grumble criticises the current tendency of Trusts to employ HCAs as nurses, nurses as doctors, etc. I have to say I have come to agree with Grumble. This is no more than providing a sub standard service on the cheap

When the concept of the Specialist Nurse was first put forward I could agree with some of the logic. Once a patient with a chronic condition had been sorted out by the consultant his ongoing care is often no more than routine monitoring, and I could accept that this work could be undertaken by a specialist nurse.

However once installed it is the case that some Trusts are extending this role to what I consider an unacceptable degree. This was brought to my attention by an old friend in general practice. He had referred a patient for a specialist opinion. After some months the patient received a letter telling him that he had a first appointment in the relevant hospital department with a specialist nurse, who would then decide whether or not the patient would go onto the waiting list to see the consultant.

This is wrong. Firstly the implication is that the nurse, with her few weeks extra training is better qualified to make this decision than an experienced GP. It is a form of rationing, and referral management combined. It is an insult to the GP, and the PCT are definitely not getting the service they are paying for.

But as ever the patient is the one that stands to suffer the most. He can be denied the specialist care that his GP thinks necessary, by someone simply not qualified to make that decision. And it is going to get worse. When you throw nurse prescribing into the mix the potential is there for patients to be seen and treated without ever having seen the specialist. They may as well never have been referred in the first place. They would be far better off had the GP managed them himself.

When management try to get the work of doctors done by nurses the potential for disaster is obvious.

This may seem like a humorous exaggeration, but the potential consequences of nurses doing the doctors job is not funny, as the case of Rebecca Cain illustrates.


  1. Sigh!

    A crass cartoon, and of course doctors NEVER misdiagnose.
    In my area patients referred with back or knee pain are first seen by a physiotherapist - any comment?


  2. Of course doctors make mistakes too, but there is now plenty of evidence that the best hospital medical service is provided by a consultant delivered (not led) service. If I had back or knee pain and was sent to a physio, I would not waste my time.

  3. I think specialist nursing has a vital place in the NHS, not as a cheaper alternative to consultants, but as an extra - an increased form of management for patients. I don't feel comfortable with nurses diagnosing. I do see the logic behind an experienced nurse doing ongoing management of an already diagnosed condition, as long as the medical care is there as a back-up.
    I was a heart failure nurse before I quit work, and that's the way we functioned. The patients all got to see the consultant first and remained on his caselist with regular check ups, and we got the routine drugs sorted out. It meant the patients could be seen for longer appointments and as frequently as necessary to manage their drug regimes, and discuss and learn how to manage their condition. Whenever things weren't straightforward, we had easy access to face to face advice from the consultant, and could book them in to see him if necessary. We also had regular teaching from the consultants. I think it was a good service - many GPs in the area thought so too, apparently: we often got referrals directly (and explicitly) to the nurses for further management of previously diagnosed patients.
    With this kind of back up I think a specialist nurse service can be very effective. But I feel uncomfortable taking my child to a nurse practioner for an initial diagnosis, and I feel concerned at some of the circumstances my former colleagues, now case managers, work under,which I feel is too autonomous, and used simply to relieve GP workload.

  4. "If I had back or knee pain and was sent to a physio, I would not waste my time."

    Of course you wouldn't, like every other doctor in the UK you would bypass the established procedures and go directly to the consultant of your choice jumping to the front of any waiting list. Not an option open even to other hospital staff.


  5. Not every other doctor, Grumpy. Mrs Dr Aust NEVER does this, but goes through the 'standard' service as a matter of principle - often to both our frustration, I have to say, when she/the kids get sent to see numpties. And before you ask, some of these numpties are doctors, and some aren't.

  6. In fact I know of one Trust which does have a "Trust employee priority system" whereby anyone who works for the trust goes to the front of the queue. It is not considered a perk but a system for minimising sickness absence.

  7. My trust tried to introduce a priority system for employees but the public made such a fuss about us 'jumping the queue' that the idea was quietly dropped.

    Dr Aust, my point was that Dr. Z would ignore a system put in place for good clinical reasons by his fellow consultants rather than see a none doctor. Also, although you and your family do go through the system the time may come when you will use your connections regardless of principle if you feel the situation warrants it. Again a situation open to every doctor but not open to others.
    And as always Dr Z cherrypicks his evidence. It's bad enough that he references newspapers, who only tell the story in black and white while ignoring the range of grays in the middle, but he uses the Daily Mail which is notoriously anti NHS.


  8. Yes, have to own up to using the daily Mail. But in fact the story is presented similarly in other papers.

  9. However I would take issue with your statement "a system put in place for good clinical reasons by his fellow consultants" Nurse practitioners and referral management are often imposed on unwilling consultants despite their objections.

  10. GP commissioning might change this strikingly.

    At least GPs will now have the choice (and not tokenistically, they really get to choose) how they want referrals to work.

    GPs in our corner have already started bickering over whether in a number of areas they will want :
    - the option of a cheaper nurse-lead servive
    - the option of a nurse/PAM-triaged service with potential access to a Consultant if clinicall needs require this
    - the option of a more expensive Consultant-lead service