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Nurses and GPs divided in support for new reforms

by Jenny Chou
9 September 2014

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A significantly higher proportion of nurses than GPs support controversial proposals to improve care such as the naming and shaming of GPs who fail to detect cancer and increasing charges for patients from outside the EU, a survey has found. 

This survey carried out by research and publishing company Cogora, found that while around 80% of GPs ‘totally disagreed’ with plans to name and shame GPs who fail to spot cancer, only 25% of nurses felt the same way. Most nurses (50%) only ‘disagreed somewhat,’ while a sizeable 25% of nurses either ‘agreed’ or ‘strongly agreed’ compared to just 3% of GPs.

While both the British Medical Association (BMA) and Royal College of Nursing (RCN) believed that the results reflected an element of GPs being naturally instinctive about protecting their sector, being the ones placed in the spotlight, each member body representative attempted to shed insight on their sector’s stance. 

The BMA GP Committee deputy chair Dr Richard Vautrey said: “[The proposed changes]  wouldn’t be effective at all. What would happen is that it would dramatically increase unnecessary referrals to hospitals and would impact on patient safety because patients would be subject to unnecessary investigations and the adverse impacts of that. GPs have a very valuable role to play as gatekeepers and GPs understand that they are making risk assessments whenever they are a making a decision about making a referral. If there’s pressure to change that they will reduce risks to themselves but increase costs to the NHS.”

Head of policy and international affairs at the RCN, Howard Catton said that while the college looked upon the delivery of great healthcare as a team game and felt that “naming and shaming” got into all kinds of “difficult territory” with respect to “scapegoating” and “blaming” individuals, he speculated that the results may reflect nurses’ extended interactions with patients and their identification with patients’ negative experiences following instances of misdiagnosis.

Catton said: “If a nurse is caring for a patient who has had a missed or delayed diagnosis, and that patient as a consequence has then had to have a treatment programme that has led to more pain and discomfort, psychological uncertainty and anxiety — because of the prolonged interaction nurses have had with patients and their families — it may be that when they see that question, should you more explicitly expose where that error was, they may be more sympathetic in saying yes.”

Nurses were also more likely to believe that placing failing GP practices under ‘special measures’ would be effective, providing an average rating of three out of five, compared to GPs who provided an average rating of two. Similarly, more nurses (52%) than GPs (38%) believed that having GPs on site in A&E would relieve the burden on urgent care, while an overwhelming 70% of nurses believed measures to charge patients outside the EU 150% of costs would help to relieve the NHS financial burden, compared to less than half that proportion of GPs.

Vautrey of the BMA said that GPs’ beliefs about the ineffectiveness of the reforms reflected their in-depth understanding of the reality of underlying issues around existing measures of quality standards for general practice, demands on urgent care unrelated to access as well as how finances are currently managed within the NHS.

“When you actually look at the reality of the figures, the burden on A&E isn’t about the referral in, it’s about the difficulty of admitting patients inside the hospital, it’s about bed blocking and patients not being discharged. Despite all the rhetoric, the reality isn’t about patients going into A&E but about problems of getting patients out of the hospital and discharged into a suitable social care environment.”

While Catton of the RCN agreed that there were discharge issues around making sure that there was the right skill mix within the district nursing teams to care for patients support needs after leaving hospital, nurses also saw a different side to challenges surrounding access to A&E that GPs weren’t as exposed to. 

He said: “There is the issue of running the system, but there are also issues about preventing people who don’t need it coming through the front door. There’s something about how nurses see access to healthcare outside of A&E and their experience of where those systems aren’t working well. What we frequently hear from nurses are concerns about inappropriate attendance. The nursing perspective on this is if you have A&Es with effective triage systems in place, then it could see and treat people more quickly and refer them elsewhere if needed. That’s what their focus is on.” 

Extrapolating about nurses’ support of measures to charge non-EU patients 150% of costs, Catton said that while it was fair to say that nurses didn’t have as intuitive a grasp of the financial implications of charging patients as GPs due to the different skill sets required for their respective roles, their responses may stem from an instinctive response to the financial challenges facing the service, heightened by their personal experience of pay freezes over several years, despite continued inflation of living costs.

Overall, Catton said that the attitudinal differences may reflect slightly different perspectives stemming from different interactions GPs and nurses have with patients and their social support systems, and that understanding these differences provided a good starting point for clinical engagement and better team working.

“We often talk about the need to invest in supporting our staff, engagement and make them feel more valued but [the NHS] is a really complicated and sophisticated organisation with a range of people from different backgrounds, and it takes energy and hard work, and the starting point is to appreciate and understand differences to employ effective team working.”