Thursday, 14 August 2008

Walk in Centre comedy

I do not normally steal stories, however for this little Pulse gem I shall make an exception. Steve Nowottny tells us just how his trip to the Walk in Centre turned out:

"Pulse's senior reporter Steve Nowottny was impressed by the local walk-in centre. Luxurious, accessible, friendly. All the things you want the NHS to be. There was only one thing wrong. No-one could help him with his problem.

Pulse team blog
At Pulse I spend a lot of time writing about primary care. But as a young, fit and – touch wood – generally healthy journalist, it’s not every day I get to see it at the sharp end.

For the past three weeks though, I’ve been suffering from a low-level cough, and yesterday I finally caved in and decided to seek help.

The thing was, I didn’t want to go to my GP. After two years of covering extended hours, polyclinics and the rise of the commuter patient, I probably should have known better.

But I didn’t want to have to make an appointment, I didn’t want to wait and I didn’t want to have to stay at home.

So I went to the walk-in centre.

It turns out there’s an NHS walk-in centre just a ten minute bus ride from Pulse Towers in central London.

It’s a little hard to find, tucked away in a shopping arcade behind a railway station. But the sign in the window promised they could deal with coughs, and once inside it was a thing of a beauty.

Luxurious padded brown leather seats. Friendly receptionists. And best of all, just two patients ahead of me in the queue.

I sat and waited my turn. It took about ten minutes, and a nurse came to get me. She was very professional. She took my blood pressure. She took a detailed history. She listened to my chest.

But she was also very candid. I didn’t appear to have anything serious, but she couldn’t be sure, and wasn’t qualified to say.

My cough shouldn’t have lasted as long as it had (this I knew already). There was a small, a very small, chance it could be something serious.

TB was even mentioned. I could try some over-the-counter treatments, she said, and reeled off a couple of names.

But my best bet, she told me - and this was before we even started - was to go and see my GP.

I rather enjoyed my trip to the walk-in centre.

As one of those young professional patients Gordon Brown wants so badly to help and private companies are advised to target, I couldn’t help thinking it was everything the NHS should be.

I was able to turn up and be seen straight away. It was easily accessible and centrally located. It was beautifully decorated. I left feeling decidedly warm and fuzzy about walk-in centres, Lord Darzi, and the health service in general.

There's was just one niggling thing. The only thing it couldn’t do was help me with my cough. Or tell me for sure it was not something to worry about.

Tomorrow, I'm calling my GP."

This amusing little tale sums up just how unproductive this government's fiddling with the public sector has been. A lot of money has been wasted creating shiny and entirely useless gimmicks. At first glance, things look great, however the government has merely created a stage upon which it acts out this pathetic game. There is no end product for all the gloss. We have numerous empowered ignorami, but alas they can do nothing of use. The NP, the PCO et al, what a great waste of our money.


the a&e charge nurse said...

So, we have a healthy young man with a cough who is well enough to go to work but won't go and see his GP........yes, that certainly sounds very familiar.

The main problem seems to be that a cough is not the right length [i.e. has lasted too long].

A definitive/unequivocal diagnosis is expected from the first consultation, perhaps because Mr Nowottny has to be back at work later the same day

TB is thrown into the mix, how exciting, of course a quack could easily overlook the night sweats, weight loss, recent visit to Pakistan, occupational exposure amongst London's homeless, etc

I can't wait for the next installment especially the GPs advice/prescription for the troublesome, yet minimally disabling cough.

Garth Marenghi said...

as always, defend a nurse no matter what their role, whether that be nursing or nuclear physicist,

nurse have their limits, why not recognise this?

the a&e charge nurse said...

Unusually touchy for you, Ferret ?

I wish I had a pound every time I encouraged patients in A&E to go and see their GP.
I have nothing but respect for them, but brilliant as most GPs undoubtably are, many would be rather cautious about giving a cast iron diagnosis on the basis of a vague symptom.

I'm totally against polyclinics, by the way, and I have many reservations about WICs as well.

I suppose I resent blanket statements about the capabilities of entire swathes of the work force based on preconceived prejudices rather than clinical realities.
Granted, some NPs may be pretty ineffectual but others are actually rather good at what they do.

I can accept that doctors [such as your good self] will never accept the NP concept, but I think you need to do a bit better if you want to denigrate their performance en masse - one or two research articles would be a good starting point.

To return to the coughing journalist I'm still not sure how the advice he was given did not seem adequate given that most doctors would have adopted a similar watch and wait approach [in the absence of any sinister features] while some might have been tempted to throw in a placebo to create the illusion that something was being done ?

Garth Marenghi said...

Yes, I'm a bit touchy at the moment, apologies.

As you know I have no problem with NPs in nursing roles, it's when they are empowered as fisher price diagnosticians that is very stupid.

jayann said...

A & E charge nurse is of course right.

the a&e charge nurse said...

Too kind, Jayann ;o)

Garth Marenghi said...

well, it'll be safe to let HCAs do a bit of triaging and diagnosis too then,

obviously until it's proven dangerous by an RCT then it must be safe!

great logic

less training = no difference in quality of service

why train anyone at all?


the a&e charge nurse said...

How many HCAs have a masters, are dual qualified [RMN/RGN] are APLS providers, etc - not to mention more than a decades experience in a given specialty ?

Overall, the research evidence seems to support NP competence/safety when we look at the various studies carried out over the last decade.

If there are certain talents in the workforce that might benefit patients, why not exploit them ?

jayann said...

You miss the point, Garth (at least, you miss what I thought the point was). The anecdote shows simply a) that there are WICs that lack doctors (but I think we knew that, they're called nurse-led WICs) and b) that nurses may not be able to locate the cause of a 'three-week low-level cough' so may have to refer a patient to their GP.

Well knock me down with a feather.

I haven't anything against nurse-led WICs (a & e charge nurse, I'll have you know, is not in favour of them) for minor problems/injuries/conditions, so long as they refer on where necessary just as, one would hope, GPs will refer on (etc.). Obviously it would be better if patients could see a GP for all conditions/problems -- though as we know, many GPs moan on and on and on and *on* about patients who take up their time with minor/self-limiting conditions... -- but that seems not to be on the cards (particularly on Saturday mornings or after 6.00 pm, or at lunchtime). So a patient has to do their own triage/Fisher Price diagnosis or go to a WIC if one's available.

why train anyone at all?

ah yes the Great GP Reductio.

the a&e charge nurse said...

Jayann, I think you have led us straight to the nub of the problem.

In a perfect, money no object sort of world ALL patients would have rapid access to an experienced clinician familiar with that persons medical history [i.e. their GP] - not only that, they would have flexibility/choice if the patient-GP relationship became fraught [for whatever reason].

But as problems in living become increasingly medicalised and the wider effects of consumerism and technology take its toll on the NHS, doctors simply cannot keep up with demand [consider the stats associated with dementia, a condition which exemplifies the growing burden for both medical and social care].

Such problems are further compounded by the generalised sort of anxiety typified by the educated young journalist, who developed a cough.

These forces have certainly been evident in A&E for some time, perhaps that's one of the reasons ENPs have been in the vanguard of quack activity [with our consultants acting as arbiters of quality control] - anything to avoid the chaos that ensues when A&E becomes grid-locked.

Inevitably boundaries become blurred and given all the crap foisted on todays junior docs I really do understand why increasing resentment is deflected toward the dilatantism of the nurse pretenders.

So, the unanswered question in mind is this:
98-99% [say] of minor complaints are exactly that, benign, self limiting conditions, sometimes exacerbated by the affects of aging, or less healthy life style choices.

The other 1 or 2% might herald significant pathology, early meningitis being one example of a perennial life threatening condition that is missed.

So, do we leave it to patients to triage themselves [as you have queried on numerous occasions, Jayann] ?
Can we trust the quacks ?
Or do we simply leave EVERYTHING to our over worked GPs ?

Perhaps this dilemma explains [at least in part] why A&E attendances continue to soar, especially during the wee small hours of the morning ?

I would be genuinely interested to hear your solutions, Ferret, after all, we are all on the same side ;o)

jayann said...

a & e charge nurse, thank you. I'd be really interested in a non-acrimonious discussion of all this!

on numerous occasions

I do know... :)

Garth Marenghi said...

yes the great GP reductio that is continually ignored, probably because it contains an undefeatable logic,

AECN, it's a debate worth having,

however it's never done honestly,

basically the less training you give to your diagnosticians then the more mistakes will be made,

it's a price you pay for the dumbing down,

personally I think anyone who is free to practice and diagnose general medical pathology independently should have a medical degree,

even with this there are lots of mistakes and lots of poor practice,

dumbing down the training needed simply increases the mistakes and the poor practice,

it's a slippery slope, the problem is that it's being done dishonestly without the obvious being admitted,

the less you pay your monkeys, the less you get out of them, if you see what I mean

jayann said...

No, Garth, not ignored. Noted and passed over, wearily, normally.

Garth Marenghi said...

ignored I'd say,

whenever I've debated these issues, it's something that people can never answer, because they simply cannot.

less training, less quality I'm afraid.

jayann said...

ignored I'd say,

because it really isn't worth taking on. Obviously it's better to have people properly trained than not properly trained. Charge nurse and I would agree with you on that. We might want to ask whether 'more training' always = 'better training', whether a more senior HCP is always better than a more junior one; but I think you'd agree with us that they are only always better ceteris paribus, so, not much need to discuss it. We might want to argue that in certain circumstances and for some purposes a specialist NP is better than a generalist doctor ( but that is probably irrelevant as the NP would not be acting 'independently' -- see below).


personally I think anyone who is free to practice and diagnose general medical pathology independently should have a medical degree,

I agree.

But this discussion was sparked off by your post. Neither charge nurse nor I accepts that the anecdote you copy shows the WIC nurse in a bad light. Obviously it would have been better for the patient if a) a GP had been available at the WIC and b) that GP had been able to say conclusively what was wrong or that nothing was wrong. My experience of going to GPs with persistent coughs, though -- something I don't normally bother to do -- is that they behave rather as the nurse did except they don't refer on.

By chance, around the same time I saw a post elsewhere about NHS Direct, complaining it refers people to their GPs. The rational complaint, I'd have thought, is that NHS Direct/WICs don't refer. It is simply not rational to argue that WICs and NHS Direct send people to doctors when they don't need to see doctors and that patients see doctors when they don't need to, AND to argue that only doctors can decide whether someone needs to see a doctor.


the less you pay your monkeys, the less you get out of them,

that's a separate point. You might want to look at the pay of Swedish doctors, who are presumably competent, before arguing this.


why train anyone at all?

see above and also consider that though we have cardiologists, we also train other people to listen to hearts; and not only GPs, at that. Though we have pain specialists and consultant anaesthetists, we also train other people to prescribe analgesics. Etc.. Why? That's your question, not mine.

I suggest you re-read charge nurse at 17 August 2008 22:03, as there are problems here your apparent stance does not address.

Dr John Crippen said...

Well, here I am on hols in Menorca and they have wi-fi, so I took a quick look at the FF. Oh dear. There is no escape.

The management of a persistent dry cough is straightforward. If there are no other physical signs (and the nurse is not competent to make that decision) you get a CXR. If there ARE some other physical signs, you act on them appropriately. That much is easy = if you have been to medical school.

But you guys (including the FF and surprisingly even Jayann) have missed the most important point. This journalist had a persistent dry cough for some time. This DOES need investigation but IT IS NOT AN EMERGENCY. An appointment with the GP in a couple of days time would have been fine. But that is no longer good enough for the middle class worried well. They want to be seen the INSTANT it occurs to them that a medical opinion might be helpful. The NHS is thus being destroyed as the government panders to these absurd demands for INSTANT attention.

Very depressing.


Garth Marenghi said...


your point about referring I do not understand, the point about WICs et al is that they can only manage such trivial disease without referral and refer on everything else, making them completely cost ineffective,

there is a threshold below which an 'HCP' is a complete waste of money and the NP working independently at a WIC falls well below this threshold,

the above anecdote shows that WICs are a complete waste of time as the disease they manage could be managed by anyone with an IQ of over 100, while the stuff they cannot manage goes to AE and GPs

basically someone is being paid rather well to do absolutely bugger all of use,

if you took someone with no medical training, who was intellifent and had a lot of common sense, then they could do what a WIC can do,

ie spot the minor and refer on everything else

that's my point, quoting snippets out of context won't help your argument

by the way the point AECN makes about AE sending people back to their GP is not a good one, as WICs are set up to be in direct competition with GPs, hence they should be able to do a similiar job to a GP practice, they shouldn't be such an inferior fisher price service,

the consultant orthopod may send a lot back to the GP, doesn't mean the consultant doesn't know what he's doing

the a&e charge nurse said...

Ferret - in 2005/6 around 2.5 million patients visited the 75 WICs in England.
[Wanless, 2007 {p8} Our Future Health Secured].

Now that's a fair few bums on seats, and to my mind begs the rather obvious question, WHY ?

Is it a reflection of the difficulties accessing GP services, perhaps ?

Or are WICs users a sub-set of thicko's who completely fail to notice the Fischer price insignia adorning the quack uniforms ?

Maybe its because there is a kind of mass hysteria with apparently healthy young adults convincing themselves they have contracted deadly diseases like TB [because of a cough].

As you know A&Es are already finding it a great strain trying to cope with year on year increases in attendence [30+% in our place since I started].

OK, supposing we do shut down the WICs.
How will this affect patients, bearing in mind that that GP out-of-hours visits have also been drastically curtailed in recent years.

What you seem to be advocating is that patients should triage themselves [in preference to being seen by a quack] then keep their fingers crossed that a doctor is available to see them before their injury or illness develops into a much more serious problem ?

jayann said...

I tried to answer earlier, but I've fallen ill!! not a 'see a doctor' thing, just a pain-and-misery one. So I'll keep this brief. I agree with charge nurse that there's a problem (demonstrated by his WICs and A & E figures) and I was hoping you'd address that. It does sound as though you want more 'patient triage'. ('More' because of course currently many patients don't see doctors or go to WICs/A & E when they have minor injuries etc..) I do think educating patients so they don't waste people's time (nurses' time included) when they've stubbed their toe or want some paracetamol is a good idea. But as charge nurse's last point suggests, it's dangerous to push that too far.

and now to bed

the a&e charge nurse said...

Hope you are feeling better soon, Jayann :o)

Anonymous said...

yep walk in centres should be staffed by docs not just nurses as they are in other developed countries

the gp model is in meltdown in the uk

but a substandard walk in centre with only nurses is not appropriate

there is no reason the working population could not have quicker easier access to doc, after all it is routine elsewhere in the developed free world

partially correct diagnosis of problem, wrong medicine

the a&e charge nurse said...

Ferret - you'll probably say all these studies are rubbish, although as a doc I'm sure you've been trained to recognise that published research data usually trumps anecdote in the evidence heirarchy ?

Anyway, Freij et al [1996] found ENPs are at least as good as SHOs in recognising the need for an x/ray and are as competent in their interpretation.

Cooper at al [2002] claim that ENP documentation was better than SHOs: same with patient satisfaction. No difference was found on missed injuries or unexpected sequelae

Sakr et al [1999] wrote in the Lancet that ENPs can provide care for patients with minor injuries that is equal or in some ways better than that provided by junior doctors.

Collins et al [2008] claim ENPs provide a rapid and efficient service and appeared to see minor injury patients faster than ED Registrars [no significant adverse clinical outcomes were associated with the ENPs].

I know I've said this many times but I do think it is highly significant that NO study [at least to date] has ever corroborated/reproduced the alarmist interpretation you attach to the quack role [and I will be generous and assume you are most concerned about patient welfare rather than professional status].

Please note that I am not denigrating docs who I think provide very good standards overall, just that the combination of post-reg training allied to years of experience enables very senior nurses to safely deal with certain types of problems [independently].

So, the question is not so much CAN nurses provide this type of role [because the research evidence suggests they can] but SHOULD they continue to do so ?

You clearly think the answer to this rhetorical question is NO, perhaps because you are overly fond of the better 'A' levels argument.
Following this line of logic it is automatically assumed [by the majority of medics] that this MUST equate to a better deal for patients in ALL situations ?
The research evidence suggests that in some instances this may not actually be the case.

Garth Marenghi said...

I've seen better scientific evidence in the Sun.

Nothing changes the fundimental point that less training and knowledge makes for a poorer service, the super weak evidence you quote makes no difference to this.

Seeing as you ask the money from WICs should have been spent improving the system we already have in place, not creating a dumbed down dysfucntional new one.

the a&e charge nurse said...

The Sun is better than the Lancet, eh ...... are you sure about that, ferret ?

Anyway, I'm sure you must be aware the States dumbed down long before the NHS, while Oz, NZ & Canada have all cottoned on to the utility value of more flexible and creative working practices - maybe these countries have got it horribly wrong too ?

If you can't accept the accumulative weight of evidence [which extends beyond the ENP studies highlighted] and more importantly the fact that none of the quack detractors [QDs] have EVER reproduced any of their [myriad] accusations in the medical journals then I suspect we are dealing with dogma rather than any meaningful exploration of the issues.

I mean it's not as though there has not been enough time for these worrying patterns to emerge, bearing in mind that the NHS quacks have been at it for well over a decade, and their clinical standards are so outrageously inferior/dangerous [according to the QDs] - could it be because no such patterns actually exist in any significant numbers, I wonder ?

Consider the following:
Patients generally like quacks, ergo patients are too dumb to appreciate they are receiving sub-optimum treatment [according to QDs].

Nurses can NEVER provide comparable standards [in certain spheres] because of the "A" level differential [according to QDs].

Professional roles and responsibilities in the NHS are immutable [according to the QDs].

From my point of view I am prepared to abandon the quack elements of my job - but if anybody asks EVER AGAIN, "when is the doctor going to see me" [even if the A&E wait has been for several hours] I might just have to grab the nearest person wearing a white coat and beat them over the head because after the 100th time [during any given week] that question really starts to get on my f**king tits.

In fact it might be quite refreshing for one or two medical colleagues to spend their days and nights in triage [for 6 month, say] just to get a flavour of how demoralising it can be acting as an apologist for a service which you have minimal control over - god forbid any of the the quacks should want to patch up some of the injuries or minor illnesses to keep things moving.

jayann said...

thank you, charge nurse. It's just a virus but I still feel a bit sleepy... !

Garth Marenghi said...


the USA's health system is a great example for us to copy, it works so so well (sarcasm intended)

by the way I've worked in Oz and they didn't have nurses let loose having a crack at general medicine with only a short dumbed down course,

i feel you are well wide of the mark there, it's always easy to make someone else's argument to be more extreme that it actually is to fight your corner,

as I have said so many times that it's getting beyond tedious, there is nothing wrong with nurses with experience being empowered in specialist nursing roles that puts their nursing expertise to good use,

what is wrong is empowering nurses in areas in which they simply have not had the education or training to practice safely or effectively,

the nurse led WICs are a cracking example of this expensive and useless dumbing down,

fortunately i don't work in AE, i work in a hospital where the vast majority of patients are very satisfied with their excellent care, there are no apologists here,

AE has been wrecked by several aspects of health care reform, by targets, and how it is now nothing more than a triage service that dumps on other specialties, it's not a competitive specialty to get into, hence the calibre of doctors is not that as it is for the more competitive areas, this has led to a vicious cycle

AE needs to be saved, but to do that would require massive investment and scrapping of targets, so that it became a proper specialty that sorted its patients out and that attracted the brighest and most motivated doctors,

in oz it's a cracking specialty and it consequently attracts much better docs,

anyway I digress,

the weight of your evidence is non existent,

it will be very interesting to see the number of negligence cases that come to court for this new breed of quacks, we'll have to wait for that,

the NHS is a closed culture in which the open reporting of crap care is actively resisted, so it's no surprise that crap care is hidden,

i've frequently heard of crap care that has been brushed under the carpet, by both medical and nursing staff, it's the crappy culture our government and ruling regime have encouraged,

ultimately the only way to monitor will be the legal cases over the next few years, even then most patients are too poor or too stupid to realise when they have been let down, meaning that the number of cases that go to court is only a small tip of the iceberg,

it's a great example of how one would do much better to rely on sensible common sense than a few crap trials that have many vested interests within,

less training and a poorer quality service I'm afraid, there are happy mediums, a lot of nurse specialists are great and their roles are very appropriate,

however the NP who is allowed to diagnose and medical general pathology unsupervised in a WIC after a few months doing a lame dumbed down nursey diploma is a f*cking scandal in my opinion, and none of your eloquent prose changes that unfortunately!