Editorial: When is a Doctor Not a Doctor?

Editorial: When is a Doctor Not a Doctor?


September 19, 2009

GPs are being kept in the dark on the qualifications of their local specialists

Not being a doctor is no longer a barrier to practising medicine. Or at least, a large number of tasks that would once have been the preserve of a clinician are now routinely done by nurses, pharmacists or allied health professionals. And it is regarded as unfashionable, or a form of medical snobbery, to complain about it.

Now, there is good evidence that the expansion in the practice nurse role, at least, has been of great benefit to patients over recent years. The QOF has driven nurses to take on far greater responsibility and they are now doing a third of all primary care work. In these tough economic times, and with healthcare spending facing a squeeze whoever is in Government next, it will be impossible to expand the scope of primary care without making full use of nurses’ skills.

But working to protocol in routine chronic disease clinics is one thing. Taking referrals from GPs and seeing patients in a supposedly highly trained, specialist capacity is quite another. Pulse’s investigation this week finds that in some NHS trusts, more than half the specialists who see patients referred by GPs are not doctors. And in 40% of hospitals, there is no policy requiring that patients should be informed that the specialist they are seeing is not medically trained. In a similar proportion, GPs are unable to insist the patient they refer is seen by a clinician.

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Our study also confirms the proportion of non-medical specialists is going up – it has risen in 41% of hospitals in the past two years, compared with 28% where it has fallen. Most GPs will have been aware of that creeping rise from experience, yet few will have been consulted over the degree to which they feel it is appropriate. Until that happens, there will be a suspicion that hospitals are altering their skill mix to cut costs rather than to promote the most appropriate care for patients.

GPs do not refer patients whose conditions could easily be sorted. It is not medical snobbery to say that in many cases those patients will be in need of specialist clinical opinion. To suggest otherwise is a kind of inverted snobbery that grossly undervalues medical training.

The most worrying aspect of our findings is the degree to which GPs and patients are kept in the dark about the qualifications of their local specialists. No longer can patients rely on the colour code of uniforms to judge whether the person seeing them is a doctor or not. And for many GPs, there is uncertainty over precisely who they are referring to, with our investigation finding senior nurses now routinely take on ‘consultant’ titles.

It is up to hospitals to make the case to GPs that a specialist service can be appropriately delivered by someone who is not medically qualified. Where that does not happen, it risks breaching the bridge of trust between primary and secondary care.

© YellowBrix 2009

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