Scrap NHS reforms, doctors tell Lords.

[Xordium]

Agree the BNF is the way to go. Seek advice, look it up to see if it's right before signing anything

Glad to see you guys saying this because an awful lot of people do not. But at the end of the day you are not the ones administering it so don't presume you are sole custodians of this knowledge. Let's face it as doctors if we mess up we can get some degree of support from our peers the nurses get thrown to the wolves but hey that's women for you

 

[heeeed]

It does not matter how they got there it matters who is most fit to do the job. So let me ask you a simple question - who is going to be the best bet to judge lets say for example a paediatric problem - the GP who has been in post for 2 years or the nurse equivalent who has most likely done A+E, ITU or HDU, has a solid theory base relevant to what they are looking at along with real practical experience - oh and who works out a darn site cheaper. Would do no harm to have such a nurse running the paeds side of things at a GP's would it. I know who I would want my kids to see - the one who, well, has experience of sick kids.

I agree that a nurse with experience is very much qualified to see those kids, but I would state that the GP is also well placed to do so. I in no way would denigrate nurses roles (imo doctors that do are likely very junior and any more senior doctor has a lot of respect for the nurses they work with) The difficulty is those paeds trained nurses are paediatric nurses and belong in paediatric units where their experience is needed. Place them into a GP surgery and they would see many other things that they arent experienced in and see less and less kids and become de-skilled in paeds. They would also lack one of the fundamental tools in paeds for minor problems which is watching a child over several hours, and primary care cannot be used in that way. The roles are really quite different between primary and secondary care and you can't make some huge secondary care for minor problems system like drunkenmaster would have. I frequently ring up the very nurse practioners I trained with in paeds for advice or for admissions and they are very much more experienced than me. However if you put them in my office seeing the same children with the same time constraints and the same lack of certain tests available at point of contact it would be quite rare that they would manage it any differently than I would.

GP's being a jack of all trades doesnt mean that they have to be crap (undoubtedly there are bad ones and if anyone watched this weeks dispatches you would see some), it is actually quite a demanding role to manage the breadth of conditions and the uncertainty that seeing the very first presentation of something can have. Most people on the forum likely dont need a GP very often and if you have only been for sore throats and bad knees that doesn't mean it's all they have seen that day and it's quite a misunderstood role even by other doctors who haven't experienced it themselves. Hopefully more and more foundation trainees going through primary care will help with that.

 

[Danthus]

Oh dear, a GP practice in Yorkshire has decided not to carry out minor operations such as the removal of skin tags and moles, only to use the patient data to write to its patients offering the same treatment privately.

http://www.bbc.co.uk/news/health-15182186

 

[stockhausen]

Oh dear, a GP practice in Yorkshire has decided not to carry out minor operations such as the removal of skin tags and moles, only to use the patient data to write to its patients offering the same treatment privately.

http://www.bbc.co.uk/news/health-15182186

That isn't entirely accurate. The GP practice hasn't exactly "decided" not to carry out minor operations, they have been told or "encouraged" to stop doing some minor ops because they are no longer NHS funded.

I believe that this is happening more and more these days and doubtless fits in quite nicely with Cameron and Lansley's plan to privatise the NHS.

There is more on this story HERE.

Don't for one minute doubt that the Tories want to privatise the NHS. They aren't going to admit that publicly but they know perfectly well that that is what their plans will eventually lead to.

 

[Xordium]

I agree that a nurse with experience is very much qualified to see those kids, but I would state that the GP is also well placed to do so. I in no way would denigrate nurses roles (imo doctors that do are likely very junior and any more senior doctor has a lot of respect for the nurses they work with) The difficulty is those paeds trained nurses are paediatric nurses and belong in paediatric units where their experience is needed. Place them into a GP surgery and they would see many other things that they arent experienced in and see less and less kids and become de-skilled in paeds. They would also lack one of the fundamental tools in paeds for minor problems which is watching a child over several hours, and primary care cannot be used in that way. The roles are really quite different between primary and secondary care and you can't make some huge secondary care for minor problems system like drunkenmaster would have. I frequently ring up the very nurse practioners I trained with in paeds for advice or for admissions and they are very much more experienced than me. However if you put them in my office seeing the same children with the same time constraints and the same lack of certain tests available at point of contact it would be quite rare that they would manage it any differently than I would.

GP's being a jack of all trades doesnt mean that they have to be crap (undoubtedly there are bad ones and if anyone watched this weeks dispatches you would see some), it is actually quite a demanding role to manage the breadth of conditions and the uncertainty that seeing the very first presentation of something can have. Most people on the forum likely dont need a GP very often and if you have only been for sore throats and bad knees that doesn't mean it's all they have seen that day and it's quite a misunderstood role even by other doctors who haven't experienced it themselves. Hopefully more and more foundation trainees going through primary care will help with that.

Well following on from this example I would argue that most GPs would not be able to do so as well on paeds - to really think with the limited exposure a GP has seems rather strange. At half the cost and with the amount of paeds seen a clinic would adequately be able to keep such a person on the books to free up GP time elsewhere. Targeting skills where they can be best applied. Agreed they are needed on the paeds units but that is a case of not enough good people to go around rather a good reason not to. And that's down to good people in the main leaving because there is no career pathway reward.

I don't believe GPs are bad I owe my daughter's life to a rather good GP and my own GP is excellent. But I do think you are looking at a very narrow skill focus of a paeds nurse or at least the ones I know if you think they can't work specifically like in the example given - lets say 6 week checks or something of that, general assessment and referral. A good paeds nurse does not need a set of 4 hrly obs to make such decisions these are people that have APLS skills i.e. above and beyond most paeds doctors and are trained to make rapid assessment, have venepuncture skills, know which blood tests to take. What you need to do is not lose these people and give them a pathway to go along so they don't all disappear which is generally what happens.

I know what you guys are saying and I am not demeaning you but let me ask you a simple question again. Who would you want to be at your local clinic when you took your child in:

A GP who has been in employment for 3 years or
A paeds nurse who had spent 10 years of their life working in an A+E at say Alder Hey, Birmingham Childrens or the Royal London and wanted a more family friendly role.

Who do you think has seen the most kids who are flat, seizing, asthmatic, etc who do you think knows how to put the parents at ease, who has heard the most VSDs that the maternity services missed etc etc. Bad example I know but I am sure you get what I am saying.

 

[heeeed]

Oh I agree for very unwell children I would generally prefer an experience paediatric nurse practioner than the vast majority of paediatric SHOs and certainly some registrars I have worked with. I'm not arguing against paeds nurses running paeds A+E and indeed locally to me they do this and very effectively. I'm arguing at GP practice level you can't bring in paediatric nurses to look after all paediatric cases as there is in no way shape or form the capacity for every single child with any illness mild or severe to be seen direct by paediatrics. Most minor childhood illnesses are looked after by GPs very succesfully without needing paediatrics help, but if they were seeing an unwell child then they would refer them to be seen urgently and most likely to a paediatric nurse, and I speak as a GP with reasonable experience of child health having worked on both general paeds and SCBU and having been trained in APLS and NLS (although I will admit these are not up to date qualifications as it would be inappropriate for me to remain current on these), level 3 training in child protection and being a child health lead and child protection lead at a practice level

 

[Xordium]

Oh I agree for very unwell children I would generally prefer an experience paediatric nurse practioner than the vast majority of paediatric SHOs and certainly some registrars I have worked with. I'm not arguing against paeds nurses running paeds A+E and indeed locally to me they do this and very effectively. I'm arguing at GP practice level you can't bring in paediatric nurses to look after all paediatric cases as there is in no way shape or form the capacity for every single child with any illness mild or severe to be seen direct by paediatrics. Most minor childhood illnesses are looked after by GPs very succesfully without needing paediatrics help, but if they were seeing an unwell child then they would refer them to be seen urgently and most likely to a paediatric nurse, and I speak as a GP with reasonable experience of child health having worked on both general paeds and SCBU and having been trained in APLS and NLS (although I will admit these are not up to date qualifications as it would be inappropriate for me to remain current on these), level 3 training in child protection and being a child health lead and child protection lead at a practice level

Most GPs do not get close to your experience though do they. And like I say I am not demeaning GPs but feel that there is a lot of stuff that could be removed from them. I am not saying that GPs can not sort out such routine things successfully I am saying other practitioners could too. I think expansion of roles to use these people before they quit the NHS would be a good solution to keeping skills in the system. Such a person in the example would be more than able to do all your 6 weeks checks would they not as well as you do them or at least your peers? And at the A+Es in the example the local demographics mean swathes of the population are using them instead of GPs so they are seeing the run-of-the-mill stuff.

 

[heeeed]

As I said I agree there are nurses who will do as good/better job than many GP's and this would be the same for pretty much every speciality going, but the number needed of these specialist nurses would be huge and there just isn't the number. The average GP practice may not see enough of each problem on a daily basis that could justify a specialist nurse in paeds, or respiratory, or sexual health or any of a multitude of other areas. Now what do you do with these staff when they dont have patients to see in their area of expertise? Im sure the paeds nurse wouldnt feel they have for instance appropriate experience in managing COPD acutely or chronically, so do they sit on their arses waiting for something to do or do you have them performing roles they aren't experienced in? what happens when the patient felt they needed to see one specialist but they are wrong? The lady who sees a respiratory nurse but it's her heart failure what happens then? can there be enough rooms in a surgery to fit all these specialists for all their areas. Although you may argue that a specialist nurse is a cheaper resource to use than a GP for a specific condition and possibly a better clinical resource based on experience (I wouldnt necessarily disagree) I would argue that a GP is a MUCH cheaper resource when you allow for the multitude of conditions that they have the experience to look after, as well as juggling the care of multiple problems for patients with comorbities and taking overal responsability for their care rather than indivdual consultants lookign after individual problems. Looking after their medication and taking responsability for safe prescribing, and providing a framework for the monitoring of chronic diseases which secondary care is often very poor at doing. I don't claim to be the ultimate resource in any one area. I'm not. I'm a generalist and very proud of that fact and find it very rewarding, but I do often think people have little understanding of why that role is important in the structure of a health service

 

[Xordium]

As I said I agree there are nurses who will do as good/better job than many GP's and this would be the same for pretty much every speciality going, but the number needed of these specialist nurses would be huge and there just isn't the number. The average GP practice may not see enough of each problem on a daily basis that could justify a specialist nurse in paeds, or respiratory, or sexual health or any of a multitude of other areas. Now what do you do with these staff when they dont have patients to see in their area of expertise? Im sure the paeds nurse wouldnt feel they have for instance appropriate experience in managing COPD acutely or chronically, so do they sit on their arses waiting for something to do or do you have them performing roles they aren't experienced in? what happens when the patient felt they needed to see one specialist but they are wrong? The lady who sees a respiratory nurse but it's her heart failure what happens then? can there be enough rooms in a surgery to fit all these specialists for all their areas. Although you may argue that a specialist nurse is a cheaper resource to use than a GP for a specific condition and possibly a better clinical resource based on experience (I wouldnt necessarily disagree) I would argue that a GP is a MUCH cheaper resource when you allow for the multitude of conditions that they have the experience to look after, as well as juggling the care of multiple problems for patients with comorbities and taking overal responsability for their care rather than indivdual consultants lookign after individual problems. Looking after their medication and taking responsability for safe prescribing, and providing a framework for the monitoring of chronic diseases which secondary care is often very poor at doing. I don't claim to be the ultimate resource in any one area. I'm not. I'm a generalist and very proud of that fact and find it very rewarding, but I do often think people have little understanding of why that role is important in the structure of a health service

Well I am not advocating getting a specialist in for each role I am advocating using it where there is scope to use such a role, in that role and to use it where it is cost effective. It strikes me you are not the your average GP and maybe I have a clouded judgement from having to pick up the pieces of GPs who are in no way interested in any responsibility and are more than happy to wash their hands of the whole affair as another one pushed out and just repeat what has been started elsewhere. But I emphasise with the fact that these are not representative of the majority. Your point about there not being enough specialists is on one hand true but in the case of paeds we are talking about a type of person that would have their time more than filled in a great many practices across the country and these people are there they have quit and taken those skills from them. My question at this point would be then if this person was doing that role then why would they then not be entitled to similar financial rewards.

I agree you should be proud of what you do and like I say I am not demeaning it and certainly don't think you can be replaced by Dolph's GoogleDoctor - type you symptoms for scary diagnosis - but the fact remains a great deal of the problems with the NHS were born from its creation and the role GPs and doctors played then. Since that time the nursing role has drastically expanded and the lines and skills held by practitioners become very blurred. Maybe it's time utilise those skills. But I expect it would be by some superGP who saw the opportunity to save a lot of money without the dedication you seem to hold and ideals you attribute to the GP we all wish we had. Wish I had of had a GP like you a few years back!

Anyway whilst we can go on forever on this one I am sure we can both agree that the government needs a good slap in regards to these changes.

 

[heeeed]

Anyway whilst we can go on forever on this one I am sure we can both agree that the government needs a good slap in regards to these changes.

on that you'll get no argument

 

[frosty03]

It does not matter how they got there it matters who is most fit to do the job. So let me ask you a simple question - who is going to be the best bet to judge lets say for example a paediatric problem - the GP who has been in post for 2 years or the nurse equivalent who has most likely done A+E, ITU or HDU, has a solid theory base relevant to what they are looking at along with real practical experience - oh and who works out a darn site cheaper. Would do no harm to have such a nurse running the paeds side of things at a GP's would it. I know who I would want my kids to see - the one who, well, has experience of sick kids.

The "equivalent" you're describing isnt really "equivalent" in any way. If you compare the nurse paeds prac/specialist, you'll be comparing it to a GP with considerably more experience. In which case, that GP will be a better judge. Trouble with specialist nurses, it's the old saying, when you have a hammer, everything looks like a nail. GPs have a broad base, like the whole toolbox.

Nurses arnt really a "darn site cheaper" once you take into account their entire cost.

I know who I would want my kids to see for making a diagnosis, and it's not the nurse. If its a chronic ongoing disease e.g. cystic fibrosis/diabetes/epilepsy, where there is an established follow up pathway then the nurses are pretty good at that. But for making an INITIAL diagnosis, then nurses are simply not trained to do that.

 

[Xordium]

But for making an INITIAL diagnosis, then nurses are simply not trained to do that.

Er, yes they are. At my last job there were about 30 of them who were trained to do just that and did it well - just as well as a GP who has a vague idea what to send some people down, no idea on some, and a pretty good idea what is the exact problem on the majority. Another example of the nursing role expanding for better or worse.

If you are a GP - then continuing with the example we are using i.e. limited application in paeds - then please detail prior to your starting as a GP exactly what practical hands on experience you had in terms of time with paeds patients I am sure people reading this would want to know about the superior practice base you are detailing. Lets stop saying GPs are the generalist - we know that - we are talking about the most appropriate practitioner to tackle a problem at the best cost. And when it comes out you are most likely going to confess to at most a years experience with paeds tops as a quite junior doctor dealing with a rather limited range of conditions. Now compare that with an experienced nurse who has ten years experience seeing the mundane, the trivial, the down right scary and all the inbetween and has been trained through advanced practice to assess in exactly the same fashion as you do then really what is the problem bar purely protecting your territory. I know this is difficult it is the exactly the same problem hospital based consultants have faced in the past and takes some coming to terms with but you see nurses on ITU sorting out the ventilation, nurses in dialysis units not ever needed a doctor, nurses in minor injury units leading, nurses in the army making initial diagnosis and commencing treatment, nurses in an awful lot of big hospitals being the first point of call for diagnosis of problems and commencement of treatment along with appropriate referral. All functioning well and providing better care the caveat being of course that there is absolutely nothing than can be done with GPs they are the special case - sounds rather like to formation of the NHS does it not.

 

[PikeyPriest]

Er, yes they are. At my last job there were about 30 of them who were trained to do just that and did it well - just as well as a GP who has a vague idea what to send some people down, no idea on some, and a pretty good idea what is the exact problem on the majority. Another example of the nursing role expanding for better or worse.

If you are a GP - then continuing with the example we are using i.e. limited application in paeds - then please detail prior to your starting as a GP exactly what practical hands on experience you had in terms of time with paeds patients I am sure people reading this would want to know about the superior practice base you are detailing. Lets stop saying GPs are the generalist - we know that - we are talking about the most appropriate practitioner to tackle a problem at the best cost. And when it comes out you are most likely going to confess to at most a years experience with paeds tops as a quite junior doctor dealing with a rather limited range of conditions. Now compare that with an experienced nurse who has ten years experience seeing the mundane, the trivial, the down right scary and all the inbetween and has been trained through advanced practice to assess in exactly the same fashion as you do then really what is the problem bar purely protecting your territory. I know this is difficult it is the exactly the same problem hospital based consultants have faced in the past and takes some coming to terms with but you see nurses on ITU sorting out the ventilation, nurses in dialysis units not ever needed a doctor, nurses in minor injury units leading, nurses in the army making initial diagnosis and commencing treatment, nurses in an awful lot of big hospitals being the first point of call for diagnosis of problems and commencement of treatment along with appropriate referral. All functioning well and providing better care the caveat being of course that there is absolutely nothing than can be done with GPs they are the special case - sounds rather like to formation of the NHS does it not.

How are paeds nurses specialist nurses ever going to be financially feasible in GP? The salary of specialist nurses you refer to is higher than junior doctors and higher than even a lot of registrars. How would this in any way help save money? Let alone the fact that GP would be a complete waste of their skills as encountering a child unwell enough for referal to paeds A&E isn't exactly common enough to have a permanent staff position.

There is a big difference between triage and management of patients. Triage is pulling up a list of what might be going, ordering tests and trying to refer to a specialty and providing basic intervention. I've seen far too many patients that have been triaged poorly to have confidence that the nurse only led system wouldn't miss a serious diagnosis.

Unfortunately further training for GPs is not mandatory and IMO not enough is done to train GPs that are notorious for very poor referrals to hospitals. There should be systems in place to address this, give feedback on referrals and give training when required.

The use of pharmacists for review repeat prescriptions is a very good place to start IMO for freeing GPs up for reviewing patients.

 

[frosty03]

Er, yes they are. At my last job there were about 30 of them who were trained to do just that and did it well - just as well as a GP who has a vague idea what to send some people down, no idea on some, and a pretty good idea what is the exact problem on the majority. Another example of the nursing role expanding for better or worse.

If you are a GP - then continuing with the example we are using i.e. limited application in paeds - then please detail prior to your starting as a GP exactly what practical hands on experience you had in terms of time with paeds patients I am sure people reading this would want to know about the superior practice base you are detailing. Lets stop saying GPs are the generalist - we know that - we are talking about the most appropriate practitioner to tackle a problem at the best cost. And when it comes out you are most likely going to confess to at most a years experience with paeds tops as a quite junior doctor dealing with a rather limited range of conditions. Now compare that with an experienced nurse who has ten years experience seeing the mundane, the trivial, the down right scary and all the inbetween and has been trained through advanced practice to assess in exactly the same fashion as you do then really what is the problem bar purely protecting your territory. I know this is difficult it is the exactly the same problem hospital based consultants have faced in the past and takes some coming to terms with but you see nurses on ITU sorting out the ventilation, nurses in dialysis units not ever needed a doctor, nurses in minor injury units leading, nurses in the army making initial diagnosis and commencing treatment, nurses in an awful lot of big hospitals being the first point of call for diagnosis of problems and commencement of treatment along with appropriate referral. All functioning well and providing better care the caveat being of course that there is absolutely nothing than can be done with GPs they are the special case - sounds rather like to formation of the NHS does it not.

You are forgetting one very important and fundamental fact. Hospital based medical staff NEVER see 95% of the cases that the GPs deal with. The GPs send only the top 5-10% to the hospital. All hospital nurses will never have the experience of seeing "cold" cases where there may actually be nothing wrong, or having something seriously wrong.

No matter how you train them, there will never be a substitute for having experience in primary care. Something that unless they actually go out to "GP land" and see all comers, they will never be able to sort the sick from the not. Dont forget they will have no access to bloods, x-ray or any other basic hospital test. Not even oxygen sats.

If you take 2 doctors graduated in the same year from med school. One becomes a chest specialist the other a GP. The chest physician will tell you that he will not be able to manage even the simplest of respiratory cases in a primary care setting. The mere realisation of this fact, is in itself a mark of a true clinician who knows his limits.

Nurses in defined clinical setting have their role, and i agree are superior to doctors. Patients already have a KNOWN problem, eg on dialysis, major trauma, etc. Even those who are "referred to" by primary care. The problem/diagnosis has already been made, and further specialist management needed. Even if you discharge blindly all patients, you will be right 95% of the time. Since a large number really have nothing life threatening to begin with.

To sort out all comers walking in off the street is not easy.To think it is, is the mark of a dangerous practitioner, who should not be allowed near ANY patients.

 

[DRZ]

I work very closely with the NHS and have worked in conjunction with 12+ Trusts, a handful of hosted services and a fairly large number of GPs.

These changes are not wanted by pretty much everyone you speak to within these places. GPs generally speaking do not understand commissioning and do not have the wealth of experience or resources that the commissioners actually have. That isn't to say that the NHS as it stands is perfect (it is far, far from it) but the way that the NHS has operated for years cannot be turned to this new direction at the pace that the Government want it to.

There is a real problem with the changes when just about everyone who actually knows what is going on opposes them. I used to hold a view very similar to Dolph's view but honestly I just couldn't continue to think along those lines once I had gained such insight into the way that the NHS actually operates - which is vastly different from the view you see as an outsider, even one that is well read on the subject.

 

[Danthus]

I work very closely with the NHS and have worked in conjunction with 12+ Trusts, a handful of hosted services and a fairly large number of GPs.

These changes are not wanted by pretty much everyone you speak to within these places. GPs generally speaking do not understand commissioning and do not have the wealth of experience or resources that the commissioners actually have. That isn't to say that the NHS as it stands is perfect (it is far, far from it) but the way that the NHS has operated for years cannot be turned to this new direction at the pace that the Government want it to.

There is a real problem with the changes when just about everyone who actually knows what is going on opposes them. I used to hold a view very similar to Dolph's view but honestly I just couldn't continue to think along those lines once I had gained such insight into the way that the NHS actually operates - which is vastly different from the view you see as an outsider, even one that is well read on the subject.

Dolph has read a report, you evidence is purely anecdotal, as were the views of two serving Police officers when Dolph was discussing Police reforms, still, he has read a report.

 

[DRZ]

Dolph has read a report, you evidence is purely anecdotal, as were the views of two serving Police officers when Dolph was discussing Police reforms, still, he has read a report.

I'm not going to "take sides" with any cynical views of another poster, I was merely using Dolph as an example of the views I previously held on this particular matter.

I do honestly wonder how many current GPs and Practice Managers were consulted before any of this started. My guess is that number is very small and those that were consulted were likely not to understand just how complicated commissioning actually is.

To give you some idea, most PCTs have teams of analysts dedicated to performance analysis, contract management, financial affairs etc. They will also have dedicated contracts managers who have legal backgrounds to review contracts for the supply of equipment and services and an accredited (usually CIPS) team of buyers dealing with all of the tendering process. There is a lot of work to do and there are a lot of brains required to make it all tick. These people are, on the whole, incredibly good at what they do - they have an in depth knowledge of the data for their areas (geographically and logically) which a GP or cluster of GPs cannot possibly know. They will know the health trends for their area but so would the PCT.

So, when the GPs are doing the commissioning, what are they going to do? They will be forced to turn to external people. Perhaps the PCT's old commissioning departments (providing their execs decide there is value there and continue providing those services). The problem there is that there is a lot of overlap between areas of expertise and you will inevitably lose out overall in the breakup. Alternatively, KPMG or Deloitte will step in but they wont have the historical knowledge to hit the ground running and it will end up in a Capita/CSC/iSoft type of horrendousness where the unstoppable forces of these vast organisations simply dessimate the GPs in terms of being able to ride roughshod over the contract process at both ends of the equation.

Dangerous and stupid. The purse strings need to be held by accountable people who actually know what they are doing - not pseudo-accountability in the form of profit-making GPs farming out billions of pounds of commissioning decisions to profit-making organisations that have no accountability whatsoever outside of a thin, unmanagable contract with a GP that doesn't understand the legalities of it all...

 

[frosty03]

Dangerous and stupid. The purse strings need to be held by accountable people who actually know what they are doing - not pseudo-accountability in the form of profit-making GPs farming out billions of pounds of commissioning decisions to profit-making organisations that have no accountability whatsoever outside of a thin, unmanagable contract with a GP that doesn't understand the legalities of it all...

I take the more cynicalview that the GPS are being setup to be the fall guys for the road to privatization, which is the ultimate aim. What better way to deflect attention than to get them to take the heat, and then once it is all done, further screw over the GPS and come to the "rescue" of the people.

 

[Xordium]

How are paeds nurses specialist nurses ever going to be financially feasible in GP? The salary of specialist nurses you refer to is higher than junior doctors and higher than even a lot of registrars.

Because as I have stated quite a few times now you would not be applying this wholescale but where it made financial sense and to an overall improvement of care. Would I expect such an initiative to be implemented in rural Bedfordshire - no - Newham yes quite possibly.

How would this in any way help save money? Let alone the fact that GP would be a complete waste of their skills as encountering a child unwell enough for referal to paeds A&E isn't exactly common enough to have a permanent staff position.

What part of the they are seeing these kinds of things already and dealing with them did you miss exactly? Do they suddenly lose their skillset when they come back to this country from doing such a role abroad? Do the magically lose their ability to work from nothing when they are placed in primary care settings?

There is a big difference between triage and management of patients. Triage is pulling up a list of what might be going, ordering tests and trying to refer to a specialty and providing basic intervention. I've seen far too many patients that have been triaged poorly to have confidence that the nurse only led system wouldn't miss a serious diagnosis.

Which tells us about the people who have worked with not the people that would be applying for these posts. Likewise I can offer you dozens of examples of sloppy work by GPs and junior doctors to know that in the main important stuff will be missed. All this means is that the people who are not performing should not be in any role they are unfit to perform.

Unfortunately further training for GPs is not mandatory and IMO not enough is done to train GPs that are notorious for very poor referrals to hospitals. There should be systems in place to address this, give feedback on referrals and give training when required.

The use of pharmacists for review repeat prescriptions is a very good place to start IMO for freeing GPs up for reviewing patients.

Totally agree here.

 

[DRZ]

I take the more cynicalview that the GPS are being setup to be the fall guys for the road to privatization, which is the ultimate aim. What better way to deflect attention than to get them to take the heat, and then once it is all done, further screw over the GPS and come to the "rescue" of the people.

I can see that in the distance because the way this is being done does seem to be deliberate - it is being set up to fail. They want the decisions made closer to the people but they don't have the necessary view of the wider picture to do it.

If they wanted to privatise the NHS they really would be better off doing it in one go and get the unpopularity over and done with rather than making things impossibly bad and then making the switch once the healthcare system is in ruins.

The NHS does have a very real need for competition in everything it does but this isn't the way to do it as it won't bring in useful competition, it will just bring about cherry-picking of the profitable services.