Saving Money and Losing Lives in the NHS

I could hardly believe my eyes when I read of the latest crackpot idea to try to save the NHS money. It’s mentioned in an opinion piece in The British Medical Journal (BMJ) by a part-time GP. It seems a scheme is being proposed to reduce demand for hospital appointments by dissuading GPs from making referrals. (At least she doesn’t say the scheme is being rolled out.) And the way this is to be done – would you believe it? – is to offer a fee of £20 ($27) for GPs who are thinking about making a referral, to seek ‘advice and guidance’ from a consultant colleague first.

It’s a long time since I worked in the NHS, but are GPs in the habit of referring to hospital as many patients as possible, or at any rate if the case is at all complicated, to save themselves the bother of dealing with these problems themselves?

If GPs need to discuss the case with a specialist colleague, is the implication that many referrals will be declined because the specialist will point out that the patient doesn’t need hospital expertise, if this is the case? And is it further believed that even if, on each occasion where advice and guidance are sought, in spite of the NHS having to fork out £20 a pop, there will be an overall saving? This assumes, of course, that GPs will not be incentivised to discuss with specialists more cases than they normally would, merely to gain another measly £20 in their pay-cheques.

This situation raises another question: why do some doctors want to become GPs in the first place? Is it for financial security and social superiority? Perish the thought.

For me, the high level of professional satisfaction of being a GP comes from doing my best to help patients, whatever their problems might be. This means being proficient, at least at the non-specialist level, in a wide field of medical practice. In other words, one is a kind of jack of all trades and often a master of one (or two), since GPs might have a special interest in, say, skin disorders (dermatology), psychiatry, or orthopaedic medicine. Thus, whatever problem the patient presents with, the GP should in most instances be able to deal with it himself or herself, and for the relatively few patients who need a specialist opinion or hospital referral, this can be made promptly and efficiently.

The writer of the BMJ piece lists two scenarios, the first of which is the situation where she wants to ask a specialist, ‘Should I be worried about this skin lesion?’

Skin disorders are diagnosed in the first instance by looking at the skin, and any GP worthy of the name should be competent to recognise common skin conditions. One would of course need to be aware that some skin lesions may be cancerous, such as malignant melanomas, and some may be indications of a more serious underlying illness. But what is the good of asking a specialist, ‘Should I be worried about this skin lesion?’ That implies the GP doesn’t know the diagnosis, so the referral would need to be made anyway. It would be unfair to expect the specialist to deal with the problem without seeing the patient face-to-face.

The second scenario is: ‘What would you try next for this complicated patient with treatment-resistant hypertension?’ The writer goes on: ‘If the reply is an instruction to do five further investigations and try two medicines…this has moved from receiving advice to being given instructions.’ Again, any self-respecting GP should be able to manage hypertension (high blood pressure), but in the relatively few cases where the patient is not responding, then he or she would need referral anyway.

It seems to me that rather than instituting a cumbersome system of paying GPs to seek advice and guidance every time they want to make a referral, in cases of real doubt there should be a way for GPs with minimal delay to discuss on the phone a patient’s problem with a hospital specialist.

An avoidable tragedy
Another item reported in the BMJ and passim, is a shocking, cringe-worthy case of a poor woman, Emily Chesterton, who lost her life because of the incompetence and ignorance of what is known as a Physician Associate (PA).

The patient attended her GP surgery complaining of pain in one calf and was seen by a PA who did not introduce herself as such; the patient assumed she was medically qualified. Without carrying out an examination the PA mis-diagnosed a muscle strain and prescribed paracetamol. A few days later, on getting worse, the patient attended again and saw the same PA. Although by that time her calf was more painful, swollen, and hard to the touch, and she had developed breathlessness, again no physical examination was carried out. The patient was deemed to be suffering from anxiety, was given inappropriate medication, and sent on her way. Later that day the patient collapsed and she died in hospital from a pulmonary embolism (blood clot in the lung).

A painful swollen calf with shortness of breath are classical symptoms of a deep vein thrombosis causing blood clots the in the lungs. The patient should have been referred to hospital as an emergency. If this had been done, as the coroner said, it is likely she would have survived.

Doctors on the cheap?
What is the role of PAs? Is it to save doctors’ valuable time? They’re supposed to work under supervision, but if every decision they make needs to be checked by a doctor, they sound more trouble than they’re worth. Not only that, but if they’re not properly supervised, as in this case, the result can be tragic.

When I qualified in medicine from the University of London after studying for five years at St Bartholomew’s Hospital in the 1960s, at a ceremony to mark our success in the final examinations, the Dean of the medical school said something along these lines: ‘Now that you’re being let loose on the public, we hope we’ve trained you to be good doctors. But at least we’re fairly sure that you won’t be dangerous.’

I believe we had a very good training, although five years was barely enough to learn all we had to know. After qualification the real work of learning began where we were responsible for our own decisions for patients under our care. Of course, for the first year as junior hospital doctors (now called resident doctors) we worked under supervision as we gained experience and confidence. Thereafter, to become proficient in our chosen fields we needed many more years of study and practice.

PAs study for a mere two years. How can this qualify them to be thrown in at the deep end and be the person of first contact with patients in general practice? Why should it be up to the patient to say, ‘I’d rather see a doctor,’ if they understand that PAs are not medically qualified?

As the above heart-breaking case shows, PAs can indeed be dangerous. The role should be abolished.

Text © Gabriel Symonds

Picture credit: Wikimedia Commons