In message <[log in to unmask]>, Nick
JENKINS <[log in to unmask]> writes
> but to say that Dr.s can't share their workload appropriately
>with other health care professionals seems a self-defeating farce...
>
Here's the nub of the question. What do you, we, HMG and the Great
British Public (to say nothing of the tabloids, m'learned friends et
al), mean by Drs' workload? My workload at present includes seeing a lot
of people who have self-limiting illnesses whose interests would be
better served by being kept away from Drs (who might prescribe wholly
unnecessary treatment and reinforce inappropriate help-seeking
behaviour). I also see a lot of people who say (like a patient today in
my "emergency" surgery) "my neighbour attacked me on New Year's Day and
I'm scared to go out of the house so can you write a letter to the
council for me?" She hadn't been to A+E, nor consulted anyone and had
one tiny healing abrasion. Is this a doctor's job? (I wrote the letter
anyway but immediately regretted it).

Of the 31 patients who attended emergency surgery there was only one
true emergency (or, more accurately, justified urgent consultation - a
perianal abscesss which required admission for incision and drainage).
Many of the others were the aforementioned minor illnesses - each of
which required a careful explanation of why they didn't need
antibiotics.

So, much of this "Drs' workload" oughtn't to be *Drs'* workload at all.
The use of nurses to give advice and reassurance, seems much more
appropriate than simply squeezing as many patients into a surgery as the
GP can get through in the time. My doubts about the advice service are
because it is separate from primary care. It should be integral to the
PHCT so that the nurses giving advice know exactly what services are
available within the team and can advise patients:

1) If the patients could manage the illness themselves, and how to do
it.
2) When to reconsult
3) If a consultation with a nurse or nurse practitioner would be
appropriate, and when.
4) If they should see another member of the team (counsellor, GP,
dietician, physio etc) and when.

and so on. 

The main problem we face is that because primary care is GP centred,
patients keep demanding to see GPs "now!!". The present patient-practice
interface is usually managed by receptionists who are no longer allowed
to be the fire-breathing dragons of former days. So they act as a
conduit rather than as a guide, have basically outlived their function
and should only book "routine" appointments (by which I mean those which
the GP or other member of the team has made available on a routine
basis). If patients want immediate advice, they should get it from a
nurse who would assess their needs and negotiate the practice's response
if they can't sort the problem out on the spot.

I'd envisage the PHC nursing team as a semi-autonomous group who will
gradually develop its own style, body of knowledge and appropriate
response to demand. Hierarchical styles of practice should go and GPs
would be able to function as doctors again - to the very great benefit
of the minority of primary care patients who actually need a medical
opinion.

Toby
-- 
Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel
0191-2811060 (home), 0191-2437000 (surgery)


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