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GPs go forth

We’ve got it narse about face when it comes to noctors


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Have you tried booking a GP appointment lately? Yeah, I know, you don’t need reminding about all the problems getting through, negotiating the system, having to wait weeks to be seen, etc etc – not least because patients waste 9.5 minutes of their precious 10-minute slot doing that for us.

But if you do manage to wangle an acute/subacute appointment, who do you reckon you’ll end up seeing? I’ll give you evens that it’ll be a nurse practitioner (typically ‘advanced’). Though whether the average punter realises that this isn’t actually, you know, a real doctor is another matter.

So what? So this. It takes 10 years to train a GP, and a significant part of that training involves learning to deal with the myriad presentations that make up acute/subacute illness. Whereas, in theory, any nurse can call herself an advanced nurse practitioner, or have that label bestowed upon her.

If you find this hard to believe, Google ‘CQC/ANP’ and there it is, right on the pages of the organisation that cares about quality: no national standard, no specific regulation. Then, with a shiny ANP badge, the nurse can be dumped on unceremoniously in the acute/subacute hot seat and just have to get on with it.

Chronic illness – GPs’ default job description – lends itself very nicely to nursey protocols

The shock of this (for nurse or patient) may be alleviated by re-badging these presentations as ‘minor illnesses’. Now, I do realise that some ‘minor illness’ is so trivial it never even gets as far as the practice, being dealt with either at home or in the pharmacy. So why get all angsty? Well, because those who doggedly pursue a GP appointment may do so for a good reason – maybe they’re a subgroup who are genuinely ill, or fear they’re genuinely ill, or who genuinely have some other agenda. Besides, I’d suggest ‘minor’ can only be a retrospective label, and I’d also suggest patients presenting with ‘tonsillitis’, ‘cough’ and ‘rash’ who turn out to have tonsillar cancer, pneumonia and leukaemia might agree.

So ‘minor’ illness might be nothing of the sort. It needs significant skill/training to spot serious pathology, resolve underlying fears, avoid over-investigating, treat causes rather than symptoms, resist unnecessary prescribing and so on.

Which means, ironically, that the trend to divide primary care labour into two strands may have it completely about face. Acute/minor is underestimated and inappropriately delegated, whereas chronic/multimorbid, currently the GP’s default job description, actually lends itself very nicely to delegatable nursey protocols. So, logically, who should do the former and who the latter? I realise this argument amounts to taking aim at the very cavalry riding over the hillside to save us. It’s just that I’m not 100% confident they can save the patients.

Maybe poorer care for better access is a deal the public is prepared to strike. But I’m not sure anyone has actually asked them, or is brave enough to. Meanwhile, to avoid a hike in iatrogenesis and costs, and a drop in efficiency and safety, if we’re going to use noctors, then maybe they should only deal with nillness.

That said, my ANPs are absolutely brilliant.

Dr Tony Copperfield is a GP in Essex 








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Readers' comments (14)

  • National Hopeless Service

    We found that when a GP goes on leave the workload increases for the remainers. But when the ANP went on leave it made no difference to GP workload. Telling.

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  • Macaque

    I work in practice with 10,000 patients in West Cumbria-most deprived part of England. We have one nurse practitioner and two prescribing nurses. They do surgeries like the GPs do.

    If they were not there, the practice would collapse.

    I think their years and years of experience make them safe and efficient clinicians, and probably better than a newly qualified GP. FYI, this was the case in rural India according to one study, where the local quacks were better than the doctors fresh out of med school!

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  • The worse NHS GP gets, the more opportunity for Doctors to escape the Stalinist NHS, and into Private Practice. The less the State spends on the NHS, the less tax we pay.

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  • Still feel that “battlefield triage” is best - most qualified person sees and sorts first, going “down” the chain to the appropriate level for the acuity.
    NHS Direct and 111 have reversed this, with tragic consequences.

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  • |This is a very pertinent article. I agree with most of what is said but the bit that is missing is that noctors taking all the quick triage stuff makes the GPs workload much harder and more depressing. They then find they cannot do a full time commitment as its too draining and we end up with lots of part timers. Agreed they help out when conditions are desperate but young GPs don't want the grim and exhausting stuff without the lighter parts and then recruitment suffers and we are into a vicious circle.

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  • Jonathan - you are spot on

    In my practice, we use triage for urgent requests, as well as nurse practitioners for more minor illness. This is the only way we can manage demand when we have recruitment issues.

    The result? I am seeing endless mental health, co-morbidity, medically unexplained symptoms and drug seeking behaviour (mainly prescribed rather than recreational)

    After a long day on Friday, I am completely spent with very little left to give to my children.

    We cannot go on like this

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    The problem is that you get 10 minutes to deal with the grim and depressing stuff..
    and it really needs 30 minutes plus
    Part time is close to full time days anyway..

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    Yep drained at end of day
    Expected to do cpd at some point as well
    get in the que family
    No time to live own life

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  • The one thing that causes us to fight with patients over scans and antibiotics is funding. There really is no need for this and we as service providers should provide within reason and safety. In the real world you get what you pay for.The system is set up so the doctors becomes the bad guy. They have complaints etc to deal with us holding the false moral high ground.

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  • I locum a fair bit and I mostly see on the day “urgent” appointments. The amount of missed and serious pathology I have to contend with is unreal. Patients have learned how to lie through their teeth to get seen and it’s not their fault. My worry is that many patients will not lie/play the system. This I’m sure leads to preventable deaths and horrendous morbidity. Is this ‘the best health system in the world ‘ ?? 🙄

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