The ‘substitution’ of GPs with ‘non-doctors’ is resulting in more patients being sent to A&E, according to a former NHS England director.
At a Sherwood Forest Hospitals’ board meeting last week, non-executive director Dr Aly Rashid said non-doctors cannot ‘distinguish between serious and less serious conditions’ meaning their ‘default position’ is to send patients to hospital.
Nottinghamshire Live reported on the meeting, which revealed that in February and March the trust saw a 10% rise in people seeking emergency care since the same period last year.
Dr Rashid, who up until last year was a medical director for NHS England in the Midlands region, said that people ringing 111 are sometimes ‘immediately directed to hospitals’. And he added that ‘unless this is eased, demand will keep rising year on year’.
He said: ‘There is a lot of substitution in primary care with non-doctors who can’t distinguish between serious and less serious conditions. Their default position will be to send the patient to hospital.’
Senior leaders at the trust expressed concerns that access problems in GP practices have led to the increase in demand at A&E.
According to chief executive Paul Robinson, the trust is trying to divert patients from its hospitals back to primary care.
This is one of the measures the trust has been forced to take to ease overcrowding over the last month.
Chief operating officer Rachel Eddie told attendees the trust has raised the issue with the ICB, and that the discussion is about ‘what primary care can do differently’.
‘There are patients coming to A&E that could be dealt with elsewhere, but it’s not a quick fix – primary care is under immense pressure,’ she added.
In response to the concerns raised at the board meeting, Nottingham and Nottinghamshire ICB medical director Dr Dave Briggs said: ‘Both primary and secondary care are under significant pressure and we are in constant dialogue with all areas of the health and care system about how we can all work better, in the best interests of our patients.
‘It is normal for patients to move both ways between primary and secondary care during their treatment, using agreed referral pathways.
‘Most referrals from primary care are made by GPs, however in some instances, other specialists such as physiotherapists or mental health practitioners may also make referrals. Who can refer will have been agreed by both primary and secondary care when the referral pathway was created.’
The ICB also highlighted that there has been ‘continued, significant growth’ in the number of GP appointments provided in the area – there were over 645,000 appointments in February, which is a 12% increase on the same month last year.
National GP leaders have raised concerns about roles such as physician associates (PAs) ‘replacing’ GPs.
BMA sessional GPs’ committee deputy chair Dr Venothan Suri recently said the Additional Roles Reimbursement Scheme (ARRS) has been a ‘Trojan horse’ in general practice resulting in GPs being ‘replaced’.
And last year, the England GP Committee passed a motion expressing concerns about the ‘increasing trend of PAs being used to substitute GPs’, and calling on practices and PCNs to halt PA recruitment.
A survey by the union revealed that over half of doctors think PAs increase rather than decrease their workload due to increasing supervision responsibilities.
Last month, NHS England sent a letter to all GP practices on the ‘safe’ integration of physician associates (PAs) into practice teams which emphasised that they are not ‘substitutes’ for GPs or junior doctors.
And the public spending watchdog concluded that NHS England’s long-term workforce ambitions are based on ‘significant’ substitution of fully-qualified GPs with trainees and SAS doctors.
READERS' COMMENTS [12]
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No shit?
substituting Drs with non Drs in secondary care increases demand on GP Practices.
all I do every Monday is see people who tried to seek help from “urgent care”
Dear All,
Senior ex NHSE Director realises that front facing the NHS with non doctors creates workload problems, no s**t Sherlock, you really earned your wages. Unfortunately this spiral of decline cannot now be unspun. It takes too long to train doctors to become GPs specialising in the management of uncertainty which is our gift for the NHS. With enough GPs fronting the NHS hospital based care was protected and could cope. Two decades of actively undermining our gatekeeper role by providing numerous alternative routes to a “signposting” whilst at the same time denigrating and “penalising” (direct quote from Jeremy Hunt when S.O.S for Health) we GPs has destroyed the infrastructure of general practice. There is not enough time to train enough GPs to fill the void. The dam is bursting. Just let it be on record that we told you so.
Regards
Paul C
Agree with @Cundy. There are other causes too. Mainly the left shift from hospital adding to the number of consultations needed prior to referral and advise and guidance requiring more work up from primary care. This has undermined the gatekeeper role. Hence the increased “GP” appointments and capacity but ongoing access issues. Also worth stopping calling these GP appointments as many as not and worth looking to see how much of the increase is due to noctors rather than actual GP appointments.
Agree with Dr Cundy too. Also that the effect on major hospital A&Es is partly due to NHS policy to close Cottage Hospitals and their A&E depts, which not only shifts those attendances to major District Hospital A&E depts, but also de-skills GPs so that the service can not be returned to in future.
As responsible GP, I would attend or deal with several A&E visits at cottage hospital any evening/night on duty, and possibly several dozen over a weekend on-call – cleaning and suturing wounds, assessing burns, setting fractures, acute illness in children and the elderly, UPSI, acute abdos, psych emergencies, Weaver and other envenomations and farming injuries, etc
Now such patients are directed to major hospital (MIU is further away, and without transport links, so not appropriate!), but because of distance, often wait several days and attend in worse condition (infected wounds repaired with string, infected burns, etc)
Another example of policy completely misunderstanding our role, training and skills.
How many of us would handle exactly the same set of chest pain symptoms with either reassurance or send to A+E depending on our knowledge of the patient and the way they present to health services.
An algorithm treats them exactly the same as does someone who doesn’t use continuity and can’t carry appropriate risk.
Original article could equally read:
‘When unable to obtain medical care, the sick will go get it from an alternative provider’
I wish doctors who were formerly NHSE employees had the guts to speak truth when they actually worked for NHSE!!
Another Pulse article exposing this Govt intentionally making the NHS fail. Suppose they’ll leave a jolly little message at the Treasury saying “there’s no NHS left” when they’re booted out…and good riddance, we deserve better.
Fund general practice properly and all these problems disappear.
A fixed, guaranteed, 11% of the total NHS budget into general practice, please. Not into PCNs and not micromanaged. We will then sort everything else out.
As far as anyone in NHS management is concerned, doctors – esp GPs – do not have any particular skills (and to state that the do means being howled down as an elitist, paternalistic…etc.). Ergo, replace someone being paid x, with someone being paid a half x, and you are saving money. Until, and unless, we can provide evidence that if you pay someone a half x, they add 3(x), or more, to total NHS costs, GPs will continue to be replaced by those who you pay a half x.
NHSE should decide what health care model they want to pursue: either the classic GP model where a proper GP manages risk and they are backed up when -by statistics- things sometimes go wrong in this professional gambling we are paid to do, or put “safe practitioners ” to the forefront, who would send every musculoskeletal chest pain and every anxious leg cramps to A&E.
You can’t have your cake and eat it!
Plus, I think very important factor that population health anxiety is so high that people want to be “just checked, and scanned and blood tested” to be on the safe side. The NHS was designed to treat the ill, not to treat all the anxious.
It goes on, acp’s subbing for drs in a&E and UCC,
Acps and paramedics diagnosing PTS at 111, and contradicting GP decisions, nurses ringing PTS who are referred by GP through onerous waits to decide how to investigate them. It goes on. A space ahp will investigate more because they know less/ can’t defend risk.
More people to hospital, more investigation, but real doctors in GP can have less faith in info coming back because we have no idea if it is Dr owned decision where Dr carries responsibility, or noctor decision with only noctor responsibility. That’s why hosp a& E and 111 don’t use titles.. drs have a hierarchy of skill and responsibility, they no longer have the title or the respect in these settings