Thursday, 31 January 2008

NICE - protocol driven monkeys

Recognising the sick feverish child is something that even the experienced paediatrician can get wrong from time to time, it is not easy by any means and requires a great deal of training, expertise and experience. General Practitioners have a solid training base to prepare them for the paediatric component of primary care, with several months of paediatrics as medical students and exams in paediatrics, followed by exposure to paediatrics in A/E and in specialist paediatric jobs. However there is probably a good argument that more rapid modern training may leave some fresh faced GPs a little unprepared in paediatrics.

NICE think that paediatrics can be put into a protocol, they think that proper training and experience can be replaced by a glossy colourful flow chart. NICE are cretins. NICE have come up with a traffic light system for recognising and managing the sick feverish child, and it perfectly demonstrates the nonsensical nature of these stupid protocols. Dr C has already humourously taken a glance at NICE's work, but I couldn't resist joining in.

Apparently if the child 'appears ill to a healthcare professional' then this is a red light sign and the child must be referred to a paediatric specialist. The 'appearing ill' part of this is completely subjective and open to interpretation, it shows that the protocol is of no use unless the person using it has the proper training and experience to know what 'appearing ill' actually is. Any doctor who does regular ward work will tell you that they are frequently called by nurses to see patients that the nurse thinks are 'very unwell', but when one arrives, the patient is sitting there eating dinner while watching the football on the box. There is a massively subjective element to this kind of judgement, and this makes a mockery of these kind of protocols.

'No smile' is an amber light, so if your 4 year old's football team lose a game and has a bit of a sniffle, and then you don't see a smile then you better get on the phone to NHS direct pretty damn quick. 'Wakes only with prolonged stimulation' is only an amber light, I'd be pretty scared about a feverish child who was that drowsy. There are other bits of nit picking I could do but you get the point.

These flow charts and protocols are useless. The protocol on its own is of no use, it requires the intelligent interpretation of an experienced doctor to be applied correctly, but the experienced doctor has no use for such a protocol. QED. This BMJ piece points out several flaws in the NICE approach for dumbies:

"This is a major concern because the most solid evidence for recognising clinical severity in febrile children in primary care is a global assessment by an experienced clinician.......To improve the care of children with feverish illness in primary care we should be offering less telephone advice and more opportunities for a prompt clinical assessment."

Precisely, the solid evidence suggests that there is no substitute for a properly trained experienced clinician, clipboard wielding numpties working to protocol cannot do the same job. If the government and its stooge agency NICE really wanted to improve the management of sick children, then they should be improving access to experienced doctors who can see these children in person. However currently we have far too much protocol driven nonsense administered by telephone and health care professionals working to protocol in an attempt to make up for inadequate levels training and experience. That's the way Stalin's NHS works, the bureaucracy proliferates exponentially and functions to limit the actual work done on the front line, more and more money goes to trying to avoid doing work, while less and less money gets through to the front line. In the end there will be no doctors and nurses and no hospitals, just a big brother speaker system eternally broadcasting words of reassurance to the people:

"Comrades, there is not time to be ill and there is no such thing as illness in the world according to the supreme leader. Anyone caught faking illness will be punished. And rest assured we are keeping a close eye on you, the Party's eyes are everywhere I assure you........."


Elaine said...

be afraid, be very afraid...

Henry North London said...

Oh for fucks sake Protocols allow people to disengage their brain.There are so many jobsworths in the NHS who will follow it to the letter and be completely lost when they cant find a protocol

Its a recipe for disaster