Wednesday, 30 January 2008

Incoherent logic - dumbing down standards

This post seemed to attract rather a lot of reaction; a lot of this reaction was rather agressive, incoherent and based on rather shaky logical foundations. Anyone who reads this blog regularly would know where I stand on this issue, but for some reason some people keep missing the points that I'm trying to make, so I thought I would stir these mucky waters again, but before I get started I'd like to make a few things clear.

Firstly the cause of this problem is the government, in a deliberate attempt to weaken the medical profession's monopoly on doctoring, they are breaking this monopoly by empowering a variety of HCPs. The reason for this is that HMG want to privatise the NHS and with a strong medical profession this would be impossible, hence the dumbing down. The same dumbing down is also taking place amongst doctors as the government also want to weaken the power that hospital specialists hold, hence the introduction the GP with special interests (GPwSI). The GPsWI is not trained to anything like the level of a specialist, often only doing a short course with no exams or assessments, but in our brave new NHS and a market of pseudo choice PCTs will happily ship work away from hospital specialists to save money. The end product for this will be a low quality privatised set of Walk in Centres and polyclinics, while a lot of excellent local hospitals with specialist services are shut. The inadequately trained PA (Physician's assistant) is another example of this shoddy dumbing down that has been brought to us from the other side of the Atlantic.

Secondly I am not criticising all HCPs. The vast majority of HCPs work very hard, and are excellent at what they do, while several of the extended HCP roles are not problematic in their nature.

Thirdly I am not criticising the motivations of any HCPs, even if working in inappropriately empowered roles, they do their best and sometimes do not have enough insight to realise when they may be well out of their depth. The blame for this lies with the government's cynical reform.

Some nurse practitioner posts (such as this example, this example and this example) perfectly encapsulate the inappropriate kind of empowerment that I want to highlight. There has been a state of denial as regards protocols being used, but this can leave us in little doubt that Dr Crippen's comments about protocol driven care are correct:
"Working autonomously to a high standard of clinical care and utilising decision support software you will assess, diagnose, and manage or advise individuals contacting the Out of Hours Clinical Assessment Unit."
Read through the job description and it is pretty clear what these kind of roles involve, it is not a nursing job, it is not a narrowed field of specialism; it is a job that would previously have required a medical degree and a significantly broader and higher level of training:

"Competently provide evidence based advice/treatment for individuals accessing the service and discharge same, or refer to another clinician within primary or secondary care, as indicated and appropriate

Practicing autonomously and using knowledge, interpersonal, history taking and assessment skills, critical thinking and professional judgement, provide competent clinical assessment for individuals presenting with undifferentiated, undiagnosed and sometimes complex conditions.

Make judgements on a range of complex issues, which require analysis, assessment and diagnosis and implementation of care."

Amazingly many of these nurse practitioner jobs, in which the job description makes it pretty clear that they will be doctoring independently, require virtually no qualifications beyond a nursing degree, it is shocking. The inconsistency shown in the different job specifications shows just how disorganised and haphazard this reform has been, no one knows how qualified a nurse has to be before they can be allowed to have a go at doctoring. By doctoring I am referring to what is conventionally termed doctoring, which is diagnosing and treating varied and unpredictable problems in an unsupervised manner.

These jobs are general roles in which one would be expected to take a history from, examine, investigate and manage patients independently, and sometimes very sick patients as the job description makes clear. Medical training and gaining a medical degree involves a far more in depth training in basic sciences such as anatomy, pharmacology and biochemistry than any nursing qualification. Medical training is also aimed at producing a doctor to do doctoring, while nursing training is not. Of course doctors are far from perfect and there are bad eggs out there, but this is not justification for empowering people with less education and training. I have written about the lack of evidence behind certain schemes of empowerment before, here, here and here.

Medicine is also a grey area
, no one is perfect and there are only degrees of safety in any system. However this does not mean that the change in the shade of grey cannot be noticed, it most certainly can. The empowering of those with far less training and far less thoroughly assessed skills can only reduce the quality of care provided. That is not to say that some of these dangerously empowered HCPs don't do a good job, some do, but on average the quality of care provided will be less than before when more training and education was required. The amount that the standard of care is reduced can be debated, however to claim that empowering those with far less training and education makes no difference is akin to insanity in my eyes.

The justification for the empowerment of the under trained is 'competency based training and assessment'. Junior doctors have come to learn how useless competency based approaches are, and how they encourage minimum standards and stifle excellence. They can also be used to pretend that training is adequate when it clearly is not, as competency is seen as a black and white entity, not the grey entity that it clearly is. The same pretence is being used in medical training, as competency based methods are used to pretend that working hours and experience are having no effect on the end product of training. The competency based model sees trainees suddenly morph into different beings once a form has been filled in.

The infamous NHS 'skills ladder' is another attempt by the government to dumb down standards by empowering those with ever decreasing levels of skill; only John Tooke has realised precisely how treacherous this path is, and is seeking to properly define the role of a doctor. The government will try to resist the Tooke review's recommendations for this very reason; Tooke is standing up for proper standards and high quality doctoring, while the government want cheap trash.

When advocates of the empowerment comment on events they often ignore the questions posed and appear to be in a state of complete denial, however they occasionally let the truth slip out as in the quote below:
"My local Trust also has what they call NP's, junior NP's etc working in the local WIC's. Many of these nurses only have their original nursing qualification, many with limited nursing experience and a 4 week clinical skills course to supposedly diagnose and treat, so yes they are sh*te! they are taught history taking using the medical model, regularly used in secondary care, so again will write similarly to the doctors."
Nurse practitioners in the roles I have described above are not as good as their medically trained equivalent. The same logic applies to physician's assistants who work completely unsupervised after their short period of dumbed down training and to GPwSIs who are doing work that was previously done by a properly trained specialist. If the under trained HCP is highly supervised then they cease to be good value for money, but on the other hand if they are allowed to practice unsupervised they they are not as good as their medically trained equivalent. In other words, a castle built on sand will never stand the test of time compared with one built on solid rock foundations.

As I have described above the dumbing down of standards is gathering apace
, the amount of education and training required to practice medicine independently is decreasing by the year, I am just amazed that some people have the audacity to claim that this will not have any effect on the standard of care provided. By this logic, training and education could be reduced to zero and anyone could then be free to have a crack, and this is clearly an absurd idea. The language of medicine is being eroded, terms including 'clinician', 'consultant' and 'practitioner' have been pirated by the new brigade of HCPs. This dumbing down has gone far too far already, and frankly none of the defences of this shoddy reform cut the mustard. HMG, stop empowering the ignorant, then you might make a bit of progress. It seems that this government doesn't want excellence or progress though, they would rather have a bunch of remote control protocol-led machines that can be easily manipulated to do exactly whatever the Supreme Leader so desires.


E said...

The job descriptions you cite are all pretty typical of the sort of guff that nursing job descriptions are typically expressed in and probably shouldn’t be taken all that seriously. I have had a number of nursing jobs in the NHS and they have only ever had a passing relationship with their job descriptions. Like policies and protocols, job descriptions either state the bleeding obvious or represent an unrealistic set of goals that no one in their right mind (which most of us are) ever aspire to.

In short job descriptions are like mission statements best taken with a pinch of salt. I am applying for jobs at the moment and I rarely even read the job description/ person spec. With a few obvious exceptions they read exactly the same only the job title changes.

Garth Marenghi said...


The problem is that I have seen and heard of many cases where HCPs are left to practice unsupervised when they are way out of their depth, it's not far on them and it's not fair on their patients.

the A&E Charge Nurse said...

Nice analysis, Ferret.

I share you concerns, and agree wth most of what you say.

It's hard not to feel pessimistic about the NuLab juggernaut, though - not least the role played by Darzi, another medical stooge it seems.

My instinct is that the grunts on the frontline are just too ground down to do very much about it.
We all know about the sham consultation processes thanks to Dr Ray (and others) - nobody apart from the bloggers seem to want to fight it.

Maybe the GP's can force the issue ?
There's always a glimmer if the likes of Rant & Co can harness the disaffection that's obviously out there.
I imagine they are torn between self preservation and tyring to maintain core NHS principles ?

But referring to colleagues as 'monkeys' (naming no names) well, don't be suprised if that gets a f**k you response from one or two of us.

Doctor rightly complain if they are stereotyped as fat-cats, or arrogant toffs, so why is it OK to abuse midwives, nurses and paramedics when all they are trying to do is play the hand they have been dealt ?

Garth Marenghi said...

Fair enough AE Charge Nurse,

GPs do have a lot of power if choose to stick together,

unfortunately there are the self interested in all groups, and the GPs in positions of power have backed many of these dumbing down reforms such as PAs, the RCGP has been very key in several of them,

also there are some rather self interested GPs who are keen to cash in by getting their hands on some of the PCT's budgets, even if this helps shut down local specialist services and replacing them with less skilled GPwSIs!

I think the debate needs to be had as a lot of others do, and it's going to be important that we don't offend people who are trying hard to do a good job, on the other hand it's important that we point out when we think things are not being done to a high enough standard,

The Tooke review has big implications for the medical profession and the current 'deprofessionalisation', this is the battle ground and we must win it,


Nurse Practitioners Save Lives said...

I definitely do not agree with nurses practicing outside of their scope and training and then calling themselves nurse pracititioners or nurse specialists as you call them over the pond. What kinds of training programs do they have to complete and with how many clinical hours? Is it standardized? Is the process in the infancy stage like it used to be in the US? Doctors here were pretty worried when we started infringing on their turf and worried whether we would take their business away and kill all of their patients. I have yet to kill one through ineptitude or any other means, and will never step outside what the US considers my scope of practice. I have a collaborating MD and work in Family practice.
I also do not feel that all NPs should be lumped into the "Quacktitioner" label.

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