Good enough general practiceBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7485.236 (Published 27 January 2005) Cite this as: BMJ 2005;330:236
All rapid responses
Lindsay's experience strikes at a matter that is very important to
It stimulates memories of a dozen or so of such encounters I had as a
GP in Wales in a previous life. I was under pressure, my hospital
colleagues were too. The consultants and registrars in neurosurgery I
spoke to were under severe pressure; anyone working in tertiary care in
the NHS was and is. I respect and acknowledge that pressure, I had to
cope with some of it as part of my own training to become a GP, most of us
Incidentally, I probably put myself in a position to encounter such
patients by doing more out of hours emergency care than most GPs like to.
The pressure from my point of view was exacerbated by my experience
of litigation by a patient with cauda equina syndrome who consulted me
when I was a registrar over a decade ago. A bad outcome meant the patient
had to follow lawyers advice and pursue me as well as others who
perhaps could have helped her more than I. An old, sad and too familiar
story, but one which leaves deep scars.
I am probably more informed about cauda equina syndrome than is
useful for a career GP.
A lot of my special education about the problem came from
neurosurgeons commenting learnedly (and at some considerable cost to the
litigant, one suspects) about exactly why all cases of suspected cauda
equina syndrome should be immediately referred to a neurosurgeon.
As the years passed, my scars were opened afresh by each
interrogation from an aggressive neurosurgeon - something that probably
happened once a year. Some registrars were certainly less well informed
about the generalities of cauda equina syndrome than I am. All of them
were necessarily less well informed about the patient sitting next to me
than I was. As a rule, consultants were ruder than registrars. One
registrar I recall fondly and still with some astonishment for his
appropriate, helpful and kind manner.
There is a point of view that of course, I couldn't possibly learn to
do a laminectomy, evacuate a subdural haematoma and manage a neurosurgical
ITU because if I could then I would have done; I bailed out and became a
GP. A much easier job. Of course. I reject that point of view and
anyone who has tried to be a good GP would reject it too. It is
relatively easy to be a bad GP, I admit, but such has never been my
So how can I rationalize and how can we resolve the recurring
Neurosurgery is the only specialty (in the UK) that can and does
refuse to assess the patient, relying instead on the assessment of others
- whilst browbeating that assessment at the same time. I suspect this is
because neurosurgery takes referrals from other hospital specialities and
can rely on the hospital hierarchy to score robust points about authority
without, usually, damaging the patients. The situation is different when
a GP is the referrer.
There are two ways out of this for the referring GP.
I suspect the best way is to rely on the strictly legal
interpretation of a referral. That is to say that the patient comes under
the responsibility of the hospital and the neurosurgical consultant at the
point when a GP rings and asks for assessment. If the neurosurgeon does
not agree to assess the patient the neurosurgeon is legally liable for a
bad (neurosurgical) outcome. This should be spelled out to the patient
and the junior neurosurgical colleage and committed to paper - and a copy
of the referral letter kept. Most uncomfortable. Patients find it
astonishing and disturbing. But they get seen by a neurosurgeon.
The easier way, for the bad GP, is to refer the patient to the
orthopaedic SHO on call, relying on his or her registrar to deal with the
neurosurgical referral. This of course allows the patient to lie in an
orthopaedic bed for some hours whilst the neurones become ischaemic under
pressure until the registrar finishes piecing together the compound
fractures from the latest RTA. But the patient is unlikely to blame the
GP and the orthopaedic consultant has broad shoulders...
Before anybody responds to me about working on the issues of quality,
teamwork, accountability, engaging colleagues constructively, reorganizing
systems, audit etc, it didn't work for me. I'm still not sure whether
this was due to my own personality deficiencies or because the relevant
neurosurgical consultants had no particular reason to listen.
So, 'we' are under pressure and so are 'they'. But legally the
pressure is not really on us and importantly the pressure need not be on
the patient's spinal cord.
I am a general practitioner and have never been a neurosurgeon
Competing interests: No competing interests