Copperfield reflects on the impact of eponymous laws from grieving families on GPs, after NHS England’s primary care director spoke in favour of ‘Jess’s Law’
Another day, another eponymous law. This time, it’s Jess’s Law, the primary care version of Martha’s Rule. And that, in case you’ve forgotten, is NHSE’s guarantee that patients under hospital care can seek an urgent second opinion on request – which is most remarkable for the fact that, as a GP, I can’t get a first opinion on begging.
There’s a bit of a problem with all these laws and rules, though. Which is that no one feels comfortable criticising an idea inspired by tragedy. But grief can cloud logic, so they require more than an awkward silence and sympathetic nodding. As the legal profession says, hard cases make bad law, and so it is with sad cases. They need cool scrutiny, with all emotions checked into the baggage locker.
Take a key aspect of Jess’s Law: legislation calling for a patient’s case to be elevated for review after third contact, aka three strikes and escalate. To be fair, there’s some sense in this. My trainer always said that a third visit for the same condition = admit. Mind you, that was in 1781.
General practice nowadays is busier and more nuanced. Strike one for any presentation might be an en-passant ‘while I’m here’ after I’ve dealt with five other issues. Strike two, a subsequent in-depth exploration. And strike three, a review after initial investigation. And that may be just the beginning of the process. But under Jess’s law, it would be game over – ignoring the fact that, as we all know, conditions evolve, diagnoses are iterative, time can be diagnostic or therapeutic.
Besides, there’s a world of difference between that scenario and the genuinely ‘getting nowhere’ third consult with no-one taking responsibility or making a plan, which maybe is what Jess’s law is getting at. Those situations absolutely do need a pause, a reset, a rethink, which is what any self-respecting GP would do.
And that’s the point. The various demands in Jess’s Law are really a plea for a functioning GP service, albeit seen through an emotionally blurred lens. It boils down to a cry for protected GP time and headspace, more flexibility in referral criteria, pathways that accommodate vague symptoms and gut feeling, prompt and constructive responses from secondary care, and greater continuity and personal contact from properly trained professionals.
Which sounds like heaven. It’s the sort of primary care paradise that needs money and man/womanpower, and is what all GPs yearn for. I certainly do, and if I wish to leave any sort of legacy as I stagger towards retirement, it’s a desperate wail for proper general practice provided by proper GPs. If you like, you can call it Copperfield’s law. Actually, don’t.
Dr Tony Copperfield is a GP in Essex
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Well said!
I too will vote for Copperfield’s Law!
As NHS manager, Dr Fuller should have genned up on ‘systems thinking’ before reflexively recommending another GP micromanaging approach. Bad laws create bad decision-making and unintended consequences, and can’t substitute for the proper funding of general practice and for gold standard continuity-of-care.
Copperfield’s first law should state “as you sow investment, so you shall receive excellent care”.
I fully agree
What about the case where you get the bloods back, crp is up and you need to order Ana, Anca etc. These are – ve so you then might just repeat crp in 1 Month.
Uhh now I refer.?
There are numerous other cases where we investigate in stages to keep down lab and radiology costs,
I would love to tick box and order all possible tests at start including lead levels, vitamin D, Urinary porphyrin, syphylis, lymes, hiv, caeruloolasmin, But I think I would be asked to leave.
This proposed “rule” had passed me by and on the face of it looks ridiculous. What about, say, every chronic condition ever discovered?
Pt still suffering from OA after 3 visits: refer
Pt’s BP still not controlled after 3 visits: refer
Pt still depressed after 3 visits: refer
… and in case Dr Fuller would reply, no the rule is for referral after 3 attendances only where there is diagnostic uncertainty, I say:
Who is to decide when there is diagnostic uncertainty?
The OA patient might have actually have inflammatory arthritis.
The patient’s BP might be high due a phaeochromocytoma
The depressed patient might have undiagnosed hyperparathyroidism
There is always diagnostic uncertainty if you look for it. Primary care is about “playing the odds” and offering horse feed before searching for zebras.
I guess the solution is to reduce everyone’s training and cut back on breadth of experience i.e. fewer qualifications gained over less time. Three strikes and you are out kind of fits the protocol driven model. Less of all this thinking please. That’s for somebody else. Primary care is simple. Everything can be done by check list. Shift all the work into the community. Leave the thinking to administrators and ‘eminent clever folk’ (who ever they are) but leave the blame with the ‘clinician’ (who ever they are) We need to clean up our act and get rid of all these messy opinions. Work at scale, shut up and do what you are told. Guaranteed dogs dinner and its all your fault
The Law of eponymous laws is that they invariably have consequences their proponents did not forsee or were oblivious to, and shift the net balance of Harm Vs Benefit into Harm.