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Rapid Responses: Rapid Responses published:
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The ongoing demise of General Practice in England! But multi-morbidity may be the stumbling block.
- Carmel M Martin (14 September 2008)
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It’s health care – not parts care
- Joachim P Sturmberg (15 September 2008)
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Current Nurse CD Prescribing Rules
- Don C Aston (20 September 2008)
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Can nurses change other prescriptions?
- Mary Hawking (22 September 2008)
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A few simple points
- Graeme Mackenzie (25 September 2008)
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Carmel M Martin, Associate Professor Family Medicine Northern ontario School of Medicine, Canada
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Sadly Sibbald is probably right! Primary Care in England is being reduced to disease management, protocol-based, and targets funded services that are increasingly privately outsourced. This is entirely an appropriate environment for nurse lead management. The general physician role and responsibilities of the previously very successful model of general practice has been gradually eroded over the recent decades, whereas nurse specialism in chronic disease management and various other components of primary care has advanced. The diagnostic work up of patients by the GP is being prohibited by very limited access to diagnostic tests and investigations, that are controlled by specialists and their teams. Discipline based consultant supervised practitioners such as radiographers, lab technicians, specialist triage teams etc are sorting and gatekeeping with a disease or target driven focus, armed with NICE protocols and guidelines. In primary care, the practice managers, primary care nurses, pharmacists and GPs are incentivised to deliver condition based care and protocol based prescribing that address the UK targets with much effort spent entering data for performance monitoring and on top of this, GPs spend many hours per week signing repeat prescription forms. Personal experiences in 2006-8 of working in urban general practice in Canada, the UK and Australia in underserved areas convince me that the UK has the ‘narrowest scope of practice’ for a GP of any of these three countries, and in my opinion the least medical care coordination. A brief hypothetical case study of the care of a person with multi-morbidity illustrates these differences in the UK and Australia. Take the reasonably common case of a person Mr X who has multiple chronic conditions including diabetes, hypertension and mild renal impairment, and with episodic unstable angina and shortness of breath, a thyroid swelling and acute on chronic low back pain with anxiety and depression. Case 1. In an East Midlands PCT, the practice was close to a medium size district general hospital and about an hour from a major centre. For Mr X: the practice nurse was prescribing the diabetes drugs in liasion with the diabetes clinic and referring directly to the renal physician acoording to guidelines; as a GP, I needed to refer the patient to the endocrinologist for investigation for the thyroid (no GP access to thyroid ultrasound); to the cardiologist or chest clinic (moderate atypical chest pain could not be investigated in practice as tropinins; CT scans were not allowed to be oredered by GPs); nor could the severe back pain be investigated or treated necessitating referral to the physiotherapist via the pain clinic (3 months wait for community physiotherapy) or the orthopaedic clinic for an MRI or CT etc. As a GP I could only councel the patient in the brief 10 minute slots, as the wait for the practice councellor was 3 months. The patient was being referred for investigation and managed by at least 6 non primary care providers with and at least two primary care providers - the practice nurse and the GP. In Australia in a simlilarly or even more rural setting with a smaller local hopital, such a patient could have all these tests requested by the GP with results in a few hours or less. GP could charge or direct bill Medicare for a longer consultation and care plan. A team care plan could be set up to coordinate the medical and non-medical care including physiotherapy, pharmacist medication review and psychology treatment by the GP and the practice nurse. The specialist in multi-morbidity is the GP. While this is 'anecdotal', health outcomes in terms of life expectancy (1), perceptions of care and cost per capita are better in Australia than in the UK.(2) Sadly, the adoption of US managed care style practices around disease management targets to contain costs is possibly costing more, causing great inconvenience and stress for the increasing number of patients with multi-morbidity, as well destroying generalism and an appropriate medical role for the GP in England. Even more unfortunately, England is a trend leader and Australia and Canada are following, seduced by the perceptions of quality and efficiency through selective performance management. References (1)United Nations World Population Prospects: 2006 revision -Table A.17[2] (2)K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The Commonwealth Fund, May 2007 Competing interests: None declared |
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Joachim P Sturmberg, Honorary A/Prof of General Practice, Monash University and University of Newcastle Wamberal, NSW 2260 - Australia
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Bonnie Sibbald’s approach to the question of who should lead the primary care team appears rather simplistic.1 Patients in my country certainly would not accept the limitations of the UK system, and many of the UK ex-patriots readily share their amazement of being able to access necessary care without fuss and having their care coordinated by their general practice. The main question to be posed should be: what is medical care supposed to achieve, and how is this best achieved? Patients (and most doctors) would propose that medical care should achieve good health, good health being the subjective experience of the people, regardless of the presence or absence of pathologies.2 Hence, health as a holistic concept cannot be reduced to 'instrumental care' of the parts as is the emerging tenet of disease- specific managed-care. In terms of the workings of consultations we know that firstly effectiveness is based on knowing each other, and secondly we know that the most important reason for the consultation is usually revealed with the door knob in the hand – regardless of whose hand it is.2-5 Trivial consultations for minor ailments and complaints are on the one hand a means for doctors and patients to gain knowledge about each other, on the other they are the ‘entry to care’ for significant – typically psychosocial – health problems. Having a good knowledge base about the patient is fundamental in the context of consultations dealing with high levels of uncertainty and complexity.2-5 Withholding such information by diverting patients to ‘instrumental care’ of minor complaints can only mean less effective, more costly and more dangerous decision-making when it matters most.6 Primary care aims to be holistic, disease-specific managed-care is fundamentally fragmentatory and ‘anti-holistic’. Team care that builds on the specific skills of – ideally practice-based – health professionals in the context of the whole person enhances care, cost-containment and health – the way people experience it, even if the underlying pathology persists. Viewed form a system perspective one needs to accept that systems function according to their design. Monetary driven health systems are designed to achieve monetary outcomes; health incentive driven health systems are designed to achieve ‘patient health’, Incentives work – so be careful what you bargain for. And finally, it should be highlighted that the Cochrane review referred to prefaces that the studies it is based on were all of poor quality!7 How does this fit with the notion of ‘good evidence’? References 1. Sibbald B. Should primary care be nurse led? Yes. British Medical Journal 2008;337:a1157. 2. Sturmberg J. The Foundations of Primary Care. Daring to be Different. Oxford San Francisco: Radcliffe Medical Press, 2007. 3. Hjortdahl P, Borchgrevink C. Continuity of care - influence of general practitioners' knowledge about their patients on use of resources in consultations. British Medical Journal 1991;303:1181-1184. 4. Hjortdahl P. The Influence of General Practitioners' Knowledge about their Patients on the Clinical Decision-Making Process. Scandinavian Journal of Primary Health Care 1992;10:290-294. 5. Gulbrandsen P, Fugelli P, Hjortdahl P. Psychosocial problems presented by patients with somatic reasons for encounter: tip of the iceberg? Family Practice 1998;15(1):1-8. 6. Hart J. Expectations of health care: promoted, managed or shared? Health Expectations 1998;1(1):3-13. 7. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews 2005. Competing interests: None declared |
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Don C Aston, retired 34, Burman Road, Shirley B90 2BG
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Professor Sibbald writes that suitably qualified nurses have been able to prescribe any licensed medicine for any medical condition, with the exception of controlled drugs since the DH guidance dated 10th November 05. But she does not reference any such guidance beyond this date. In fact nurse independent prescribers may now prescribe most opioids and major sedatives mainly but not exclusively in connection with palliative care and by most routes ( oral, parenteral, transdermal, rectal and buccal ). Also any CD that is included in a patient`s clinical management plan and agreed by a doctor ( DH guidance last modified 31/7/07 ). Problems may still arise when CDs are administered by an unlicensed route eg diamorphine and Midazolam in a syringe-driver which would still require a doctor`s authority. Competing interests: None declared |
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Mary Hawking, GP Kingsbury Court Surgery, Dunstable LU5 4RS
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If you look at responsibilities in a SSEPR (single shared electronic patient record), one of the issues identified [1] is the responsibility for overall management of the record - including prescribing. Nurses can be Independent Prescribers but can they cancel prescriptions initiated elsewhere or for different conditions, and does their enhanced training cover this routine GP function? In a chronic condition - such as diabetes - starting one medication will often mean discontinuing something else - which may have been prescribed for a dual purpose. Who is responsible? [1] www.phcsg.org.uk summer conference 1st July 2008 stream 2 15:20 "Safety in single shared electronic patient records" Competing interests: None declared |
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Graeme Mackenzie, OUT OF HOURS GP North Cumbria
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A nurse led service with restoration of the full gatekeeper role probably could work. A nurse led service would address the ridiculous contact rates of some GPs. I like the idea of the GP as a primary care consultant. With time AND RESOURCES, I suspect most GPS could reduce elective and even emergency referrals to secondary care by up to 50 %. With more time and dedicated time off every week to address their knowledge needs, GPs could address some of their chronic knowledge deficiencies in some areas that flow from the set up of the current system. Nurses in primary care are already doing this. Secondary care almost certainly would never release resources as a result of a reduction in referral rates. How would you fund the expansion of primary care without that release? Reduction of the current GP workforce would create a "crisis" in medical employment that could take 20 years to wash out of the system. Traditional medical degrees would become somewhat obsolete. Why spend many thousands and all those years if there were far fewer jobs and mostly in secondary care? Forget the term "nurses". Just train primary care physicians from the start. A new medical degree would just be for potential specialists. Actually many aspects of secondary care could be done by "nurses" even more easily than primary care. This whole debate could go around in a circle and you end up with a new breed of doctors/nurses or whatever you want to call them. Reduction of salaries as a result of nursing taking over, will mean applicants will likely change signficantly. Many doctors like earning well and would not be interested in a career at half the pay. and so I could go on. Competing interests: None declared |
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