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At the heart of general practice since 1960

GP fury over PCT's refusal to fund enhanced services

One of my 36-year-old patients with a history of angina was referred through the rapid access chest pain clinic and subsequently seen at our local nurse-led cardiology clinic. Despite his chest pain, high-risk profile, abnormal resting ECG and borderline ST segment changes on ETT, he was sent for a myoview scan.

At review 10 weeks later the patient was reassured and advised to continue with medical treatment ­ on the basis of a near normal report.

The patient was admitted to the local hospital as an emergency with acute coronary syndrome on 12 September.

A coronary angiogram on 21 September revealed significant underlying multi-vessel

disease ­ 75-94 per cent stenosis in all vessels ­ despite a normal flow. Fortunately, the patient is now recovering from uncomplicated CABG surgery carried out on 30 September.

Given the high-risk profile of this patient, whose father died age 58 due to MI, familial hyperlipidaemia and diabetes, the patient should have been referred for coronary angiography in the first instance instead of a Myoview scan that was carried out 10 weeks after an equivocal ETT report.

A strategy of initial CABG surgery is associated with lower mortality than one of medical management with delayed surgery if necessary, especially in high- and medium-risk patients with stable coronary heart disease (Lancet, 1994:344563-70).

This can only be achieved if we adopt a proactive approach in high-risk patients by performing early diagnostic coronary angiography even if the ETT is negative (false-negative rate of 37 per cent).

Sadly, in this politically driven health service aimed at reducing waiting lists, our patients are now pushed through nurse-led clinics driven by protocols. As a result we are bound to witness an increasing number of patients being put at risk of inappropriate clinical management.

As a qualified and trained doctor, when I decide to refer a patient for consultant opinion, I similarly expect the patient to be seen by an appropriately qualified and trained doctor and not a nurse.

Whichever way we look at the current number crunching and data-orientated health care strategy, the medical profession must accept the blame for the fragmentation of clinical care and its consequences.

As a solo GP I consider my self fortunate that I am in a position to provide continuity of care to my patients from cradle to grave.

This is the fundamental principle on which our NHS was founded.

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