Tuesday 8 November 2011

Above my pay grade

"71 year old male, shortness of breath"

I don't profess to be a GP, nor do I wish to be or act like one. Like nurses GP's range in quality from helpful and polite, to rude, obnoxious and verging on negligent. Many wasted ambulance hours are spent picking up the slack for GP's not willing to do their bit and simply taking the easy option and clogging up a hospital. This is party due to a lack of GP's available during out-of-office hours and partly, in my opinion due to laziness. One consequence of the opt-out policy, which was part of the new GP contracts which came into effect in April 2004, is that the overwhelming majority of England's 298 primary care trusts were left with a huge gap in their budgets as they take on the burden of the out-of-hour service. A burden that has not been dealt with correctly and one which is causing unnecessary strain on hospitals and the ambulance service. Ask any member of the ambulance service, or any nurses if they wanted to 'opt out' of working crap hours and you'd get a resounding yes. There are 24 hours in a day and unsurprisingly, people are in fact ill, between 5pm and 9am. Shocker! 

In recent years ambulance services have begun to move away from just taking everyone to hospital. In fact, if a patient can be referred and left at home that is preferred. One of the alternate care pathways (ACP) is a GP referral. We assess the patient, if they don't need to go, or refuse to go, we arrange a GP to call or visit. This applies to the out-of-hours GP service too. And in general it works quite well, a GP will ring, talk to the patient and either make an appointment or come and visit. On occasions where we have concerns for the patient we will speak to the GP and politely request / insist they do visit. Like with everything, you get good and bad GP's. Some will come out at any hour, will do the right thing, go the extra mile and be polite and courteous whereas others, won't come out for love nor money, will be dismissive rude and lazy. I mean, it's not as if we should expect them to see ill people at night on a meagre £100,000+ salary. Absurd!

This particular job, was very common. An elderly guy, having trouble breathing, but despite all the advise in the world refuses hospital. I'd imagine it's partly from pride and wanting to not be a burden and partly fear, not wanting to die in hospital. Either way, he wasn't going. We did all of our checks, the full work up, sitting and standing blood pressures, ECG and a advanced respiratory assessment. We arranged a GP referral and said to our control it was imperative that a GP visited this guy. We completed the necessary paperwork and went back to the truck! Not 3 minutes later, and our patient appeared at the door, beckoning us to return. He told us the GP had just phoned, didn't ask any questions about how he was etc and told the patient to make his own way to the local hospital and see a Doctor there. Needless to say, our patient told us he wouldn't be going to hospital.

Steam pouring out of my ears I phoned control and asked that the GP phone me directly on my mobile. I was livid. What is the point? What chance do we have of unclogging emergency departments when the ACP's in place can be abused by the unwilling and lazy. After 15 minutes my phone rang. It was the GP.

"Hello there, I was informed you wanted to talk to me"

"We requested a GP visit for this patient as he has poor mobility and would benefit from seeing someone with the ability to prescribe medication, the patient isn't well but is too scared of hospitals to go. He says he was told to make his own way to hospital"

"That's correct, I assessed him over the phone"

"You didn't ask him any questions about his health, his mobility or reasons for refusing hospital, he uses a frame, has no family and is scared"

"Well if you're that concerned you should have taken him in"

"We can't kidnap him, he has capacity and has refused admission. That's why we referred to you"

"In all honesty love, you are talking above your pay grade, I've made my decision, and you aren't qualified to question me"

Wow! He picked the wrong girl to mess with tonight. Needless to say, an argument in sued. It wasn't an argument I was ever going to win but one that made me feel better. I was able to rant about all the above. I told him exactly what I thought of him and I didn't hold back either! I went to town on him. We exchanged names for counter complaints, I even offered my call sign and personnel number. Pay grade, really? He went there? The arrogance and self proclaimed greatness was enough to make me seethe for hours and I did. It was like a red flag to a bull. My crew mate looked on in fear as I screamed and shouted (off the phone by now) at him about bloody GP's. When will they realise that we are no longer stretcher monkeys. Many have degrees in paramedic science, some have masters, there are Emergency Care Practitioners and in general, we are good at determining if someone is ill. When will we get the respect we deserve? We all work for the same team and the sooner the other medical professionals stop treating us like the kid that was never picked for anything, the better state the NHS will be in. By 'better state the NHS will be in' I mean the happier I will be! Lets be honest, being nice won't make a blind bit of difference to the NHS as a whole other than remove animosity and ill feeling between two bodies of people who are essentially working for the same team!


  1. Bloody well done!!

  2. Good job ! About time someone answered back :o)

  3. Brave.... Did the patient need to go in? Was he CURB 65 positive? What was the expectation that the GP could deliver? Was it ABs and steroids? If he had capacity and refused your advice then there is an arguement to say that there was no need for a visit. Why was the patient not empowered to call the GP themselves? One alternate care pathway(or pathway as I hate the term alternate) is us taking that decision on our professional heads and no longer rely on others to "cover our collective ass". You advised to go, he refused give the patient options and move on.

    1. I believe the patient did need to go in. I believe he didn't want to because of fear. He had no means to get himself there either. I would most definitely have benefited from an assessment from someone more capable and medically trained than us. He needed a diagnosis and medication. We cannot prescribe. We cannot force people to go even if they need it. What we can do is refer to a GP if and when we feel it would be of benefit. How can a GP be happy with a patients condition without asking anything, without reading our paperwork? How can a GP ask an elderly patient with reduced mobility to simply make their own way? I don't think it is brave, I just don't thing salary should have a bearing on a discussion about a patient. Do you?

  4. Talking about salary is unproffesional I agree and unessesarily antagonistic, is it more about the level of risk being undertaken? As the patient was talking and able to get to door could it not have waited till the morning to see own GP having been seen by professional ambulance crew?Is this not really about handing over patient care? Was there any way to get patient to where GP was, family member etc? Most importantly what was the outcome? Was he left? Was he happy?Good to see this constant problem being debated.

    1. I can only see it from my ambulance perspective. Likeways there is another view to that of the GP. I imagine if the GPs reasons had been explained rather than have standoffish comments then maybe id have felt better about it. Don't get me wrong, I refer to GPs every day, most probably don't visit, some do and very rarely are they rude. This was a somewhat isolated incident.

      Re the patient, he didn't go, he wasn't happy about and neither were we. With a clear head, yes, he probably would have been fine to the morning. Probably. It didn't sit well with me though! Thanks for your coments. I do appreciate hearing and discussing the other view point. Its what the whole NHS needs!

  5. Increasingly the ambulance service is acting as the visiting clinician. With our higher level of training coupled with more professional accountability it is an area that we need to take ownership of.It is up to us to drive new pathways that meet patient need. Balancing the expectation of the patient whilst dealing with the reality will be a challange. However forums like this will highlight poor service provision and promote debate which will benefit the patients we all serve.

    1. Very good point. There is not enough scope or willingness at work to share experiences and say to each other what we expect and what can do. Whilst I moan about various GPs I have no doubt GPs get ambulance crews who are rude and not acting to the standard expected of them. I know GPs workload is huge and it's easy to point the finger and say they should do more but everyone in the NHS needs to work as one if it is going to stave off privatisation.

    2. On all that evidence any reasonable person would would have acted. Obviously that doctor was not a doctor in the hippocratic sense.


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