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At the heart of general practice since 1960

The risks of noctors, phoctors & mocktors

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Lying on a beach sipping an ice cold mocktail seems a distant memory to me now, with summer well and truly over. Don’t you just love the term mocktail? It’s a cocktail but without any of the alcohol. It’s a bit like ‘noctor’ – a word I’ve never been entirely sure about. Is it anyone who is not a doctor? Is it a nurse acting as a doctor? Is a ‘phoctor’ a pharmacist performing our role or an orthopaedic physiotherapist running a spinal clinic? And what of the newest addition to this lexicon – a physician associate? 

What all these professionals have in common is this – they are not medical doctors. They are highly trained and skilled professionals in their own right, and know their subject area in greater depth than us. But they are not generalists and they were never trained to manage risk and uncertainty.

We all know the impossible balancing act that is happening in primary care right now. Patient demand is escalating and GP numbers are dwindling. We can do one of two things to put this right: manage demand or increase GP numbers. As the former is political suicide and the latter entails cloning, the Government (supported by our college) has decided to increase the numbers of noctors, phoctors and mocktors (mock doctors).

If you carry the medicolegal risk of six other individuals as well as yourself, what do you do?

Just to be clear – I fully support multidisciplinary working. Our practice was one of the first in the area to employ a nurse practitioner and we also have a practice nurse partner who is worth her weight in gold (and more). My concerns lie mainly around the medicolegal risks of delegation. At the moment, the medical defence organisations are happy to cover the indemnity of the odd one or two nurses, within a group premium. However, if there are more non-doctors than doctors to cover within the group, they are certain to be less generous. And these indemnity fees are likely to be even greater than the current astronomical costs of GP indemnity because the risks will be perceived as higher. The real question is, who will pay for it? I have a sneaking suspicion it will fall on the shoulders of the partnership, unless we make a stand as a profession about indemnity fees.

So in this brave new world of general practice, we will have large super-practices run by a handful of GP partners (or more likely by Virgin) with a large salaried payroll consisting of GPs and various mocktors. As a salaried GP, you will be consulting, as usual, at 10-minute intervals. In addition, you will be answering dozens of messages flashing up on your screen as you will be supervising two trainees, two nurse practitioners, a pharmacist and a physiotherapist. Then at the end of morning surgery, you will be debriefing six other professionals before starting to wade through the blood tests and letters diverted to you as the only one who can fully interpret them.

If you carry the medicolegal risk of six other individuals as well as yourself, what do you do? Well, it’s obvious isn’t it? You go shopping for some shorts and suntan cream and buy a one-way ticket to Australia. And GP numbers will dwindle further…

 Dr Shaba Nabi is a GP trainer in Bristol

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Readers' comments (76)

  • "And GP numbers will dwindle further…"

    That is their plan Shaba. In the governments eye we are too many chefs that are spoiling their broth. Inverse pyramid or right-side-up one? Are they our worst enemy or do they have a point? Time will tell...

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  • 'they were never trained to manage risk and uncertainty' wonder what those in your own practice who 'are worth their weight in gold' think of this very uninformed and actually very insulting remark.

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  • The less nunber of GPs the better for RCGP.
    RCGP wants less GPs and hence id hand in glove with government.
    It is paying a deaf ear to physician associates.
    I think you have to foght with RCGP who is the main culprit here.

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  • Australia is following the mistakes of the UK so there is no point coming here (to Australia)

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  • Please elaborate on these mistakes.

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  • Completely agree with all the points faised above. Personally I would never again agree to supervise the work of ANP or Physician Associate (I have done it before in a walk in centre and it was extremely stressful ). Why any sane GP would want to carry this extra risk is beyond me . Its really simple - if you want to want to truly be an independent medical practitioner managing risk and uncertainty then get into medical school , get MBChB and MRCGP.

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  • @Anonymous | Other healthcare professional16 Oct 2015 11:04am

    Obviously you are not a GP hence you have no way of knowing how much uncertainty we manage. The governments it self has no clue how much uncertainty we manage. The public doesnt know how much uncertainty we manage. What we do as GPs is not obvious. Its very complicated in fact and we are mainly to blame for being so modest and generous with our skills.
    I do not expect you to understand but I expect you to show respect to Shaba who I am sure knows more about being a GP and the challenges we face than you.

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  • The indemnity fees for a pharmacist are £150 to £200 per year slightly more if they work in a GP surgery. A Gp if they do out of hours is £3-15k. This equates to a lot more risk.

    At the end of the day if the other roles can deliver this will be reflected in terms of cost and indemnity. Unless government bans an independent judiciary which, it may love to if it could, and stops litigation and or / GPs stop supervising these other roles and went private and contracted back AT THEIR RATES and not the STATE MONOPOLY's ones then a few high profile noctor and phoctor disasters could bring the whole house of cards down.

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  • "But they are not generalists and they were never trained to manage risk and uncertainty."

    They are not as well trained and do not have the capacity to do a GP or increasingly general physician's job full stop. You cannot do a GP's job on the cheap and cut corners. It takes ten years minimum to become a GP after getting straight A's at A level or a first class / double first plus a PhD at graduate level. Of these medical students, many fall by the way side before even reaching GP land.

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  • Anyone can do a GPs job. GPs need to get off their high horses and understand that they are not specialists. An ENP can deal with minor illnesses, a PA can check a BP and offer lifestyle advice. A pharmacist can manage a whole host of minor ailments. In an ideal world you would want to see a super clinic run by a GP, who would deal with the more "complex" stuff in GP, with a team of pharmacists, ENP, ANP, PA etc etc to deal with the minor stuff.

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