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Gold, incentives and meh

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)

  • Well...as an epilepsy specialist nurse,trained to Masters level, investigating, diagnosing and treating independently, covered by my own indemnity, receiving 10-20 phone calls each day from GP and ward medical colleagues from F1 to Consultant level, asking my advice, and acting on it, and apparently valuing it, I wonder whether the author has been exposed to the full range of us "noctors", and seen the level at which some, of course not all, work. I would not wish to criticise colleagues but I daily see, to put it mildly, less than adequate management of what I consider straighforward clinical scenarios by medics who don't appear to have access to a BNF, let alone the ability to Google the latest guidelines. There are thick doctors, there are bright nurses. We all need to work together and stop the patronising. My GP colleagues I know would disagree with the attitudes shown in this article.

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  • Glad I work with a more enlightened bunch of GPs who delegate appropriately to PNs annd ANP so that they can concentrate on the bit they do so well i.e dealing with complex patients comorbidities.

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  • GPs in Australia do so much more - skin cancer excisions, injury management such as plastering fractures, closing wounds, acute illness management, sometimes hospital care as well. This is what patients want over here, and they still respect and value GPs. U.K. GPs have become too de-skilled and need to turn this around if they want to maintain or improve their status.

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  • May I expand on the lines in the sand we have crossed
    • if our patient get a serious chronic illness it's off to nurse clinic they go goodbye to whole patient doctoring we signed up to when we became GP's
    • by abandoning out of hours again we showed our contempt for the times our patients may need us most
    • by accepting ( for money) a degrading contract that paid us for doing what we should be doing we said goodbye to being professional people and by the way any street cred
    Try offering a plumber or plasterer similar terms and see what they would say
    • by accepting ( for a peaceful life ) that we do not have time to treat and listen to our patients properly we have betrayed them and ourselves
    Sorry my friends every bit of the mess we are now in is due to ourselves and the lies our negotiators told us that we had no choice

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  • Agree with some of David Hogg's remarks re GP/ OOH and totally agree regarding remarks regarding all the work nurses do in General Practice. This generates a lot of income. Remember this?? Cannot have it always I am afraid. It is disrespectful stating about qualifications as many nurses are extremely well qualified both academically and in years of experience. If you are general nurse/ midwife and ANP/prescriber you have trained for at least 7 years. Then add on all the other courses we do in General Practice. Totally agree with the epilepsy specialist nurse. I work in a busy GP Practice as ANP. I took the decision to undertake this role at the request of GP Partners to alleviate their pressures when they were short of staff and finding recruitment difficult. It was Dr's wanting this. I feel I do alleviate pressure. I am like all other nurses accountable for my own actions. I also agree with comments from others we need to stop having a "go" at each others roles and work together as a team. Thankfully there are plenty of well enlightened and grateful Dr's who value Nurses. We all need each other so we should all acknowledge and respect each other. MSK specialists do a great job. There is not one GP on the planet who does not need the help of other team members.

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  • Australian GPs do a lot more.In contrast British general practice is a soul sucking brain dead job.ANPs and PAs will hopefully form the backbone of future primary care.

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  • As a Phoctor myself, I have to confess that I agree with most of the above. But it appears that this is the way the service is being pushed. And it is because the change is being pushed, rather than embraced, that is why I am particularly careful to resist the managerial pressure and and focus on gaining of the trust of the physicians I work with. There is no point in GPs complaining about pressure of workload whilst not delegating jobs down, any more than me expecting politicians to know what the **** they are talking about. I still have to get on and do the job though.

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  • In the long run unless you have a medical degree you wont be the one carrying the can when things go wrong.The ultimate responsibility is always the doctors.

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  • Anonymous Nurse.17th Oct 6.14pm

    I read your comments with great interest but wonder if you could clarify the point about indemnity.As I understand it hospital workers who require indemnity are covered by Crown Immunity ie litigation is paid for by the taxpayer.Anps and Pns in GPs land in my neck of the woods are covered by a vicarious liability clause in the practice/gps medical insurance and therefore the practice/gp is responsible for acts of omission etc amounting to medical negligence.Have you had any complaints regarding your diagnosis with or without investigation and subsequent treatment of the patient?.Are your consultant colleagues willing to back you up?.I was informed by my medical defence union that if I am advised to prescribe a drug by a nursing colleague any problems which resulted would be my responsibility.This caused caused considerable discomfiture as I do not necessarily know the nurse concerned.
    My problem is that it is difficult to see where the nursing aspect comes in when reading of your career progression into what sounds more like a medical role than a nursing one.It is sometimes difficult to see where the nursing role ends and the medical one begins.Presumably there are still nurses who prefer to follow a more traditional nursing role because I rate professional nursing care in a ward as one of the most important jobs done in hospital and if what patients tell me is correct this has become less effective in the last 15yrs..
    Peoples opinions on this would be interesting

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  • Anonymous Nurse.17th Oct 6.14pm

    I read your comments with great interest but wonder if you could clarify the point about indemnity.As I understand it hospital workers who require indemnity are covered by Crown Immunity ie litigation is paid for by the taxpayer.Anps and Pns in GPs land in my neck of the woods are covered by a vicarious liability clause in the practice/gps medical insurance and therefore the practice/gp is responsible for acts of omission etc amounting to medical negligence.Have you had any complaints regarding your diagnosis with or without investigation and subsequent treatment of the patient?.Are your consultant colleagues willing to back you up?.I was informed by my medical defence union that if I am advised to prescribe a drug by a nursing colleague any problems which resulted would be my responsibility.This caused caused considerable discomfiture as I do not necessarily know the nurse concerned.
    My problem is that it is difficult to see where the nursing aspect comes in when reading of your career progression into what sounds more like a medical role than a nursing one.It is sometimes difficult to see where the nursing role ends and the medical one begins.Presumably there are still nurses who prefer to follow a more traditional nursing role because I rate professional nursing care in a ward as one of the most important jobs done in hospital and if what patients tell me is correct this has become less effective in the last 15yrs..
    Peoples opinions on this would be interesting

    Unsuitable or offensive? Report this comment

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