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