Monday, October 09, 2006

Tomorrow's world?

The NHS of tomorrow

Mr Smith has been experiencing abdominal pain for 12 hours, its getting worse so he calls the doctor. Due to changes in ‘unscheduled care’ he is unable to speak to his own GP and is put through to NHS Direct.

Here after giving his details to a telephonist he is put through to a nurse advisor, he asks him lots of questions and follows the computer prompts which result in calling out a paramedic practioner. The paramedic duly arrives, asks many of the same questions and attempts to examine the abdomen. She is uncertain as to what she has found as her training in abdominal examination has been rather scanty and her supervised experience of assessing such patients is slim. Her knowledge of anatomy is also a little patchy, so she calls an ambulance for Mr Smith to take him to hospital.

In A+E the triage nurse, the emergency nurse practioner and an A+E nurse see him. They all agree that he may have something going on his abdomen, so they send for the surgical assessment nurse practioner. The SNP asks many of the same questions, orders some x-rays and takes some blood. He is uncertain as to the cause but thinks it might be appendicitis. He sends for the emergency surgical practioner who agrees that appendicitis is likely and wants to take the patient to theatre.

The Anaesthetic practioner is sent for, she is happy to anaesthetise Mr Smith as he is a fit and well gent who would appear to present no anaesthetic challenges. The patient is taken to theatre and surgery commences. On opening the abdomen the appendix cannot be found as the caecum has been infiltrated with cancer and has perforated. The hemi-colectomy nurse practioner is away on a course so the surgical doctor is sent for. He has not done many hemi-colectomties as the NP seems so very keen to do them all, so his boss is sent for.

The surgery proceeds uneventfully, but at the end of the operation the patient does not start breathing. It would appear that he has had a rare reaction to the paralysing agent used to intubate. The Critical Care practioner is called who agrees to take the patient to ITU, the central line insertion technician is called and lines are duly inserted. 24 hours later the patient is able to be weaned from the ventilator and returns to the ward. He is looked after by a range of nurse practioners and ward nurses until eventually being fit enough to go home.

The NHS of today

Man sees his GP –‘it might be appendicitis old boy’, GP refers to the surgeons, who see him, agree that it is likely to be appendicitis and take him to theatre. He is anaesthetised by a medical anaesthetist. When it is discovered that he has a tumour, the same surgeon continues to resect the lesion. At the end of the op he doesn’t wake up, the anaesthetist diagnoses the problem, inserts the appropriate monitoring lines and takes the patient to ITU. Along side this activity work groups of highly skilled nurses and other professionals who ensure the whole team work smoothly together.

You may think I’m joking……just you wait. Lulled by the ‘logic of the salary cost’ and lobbying by activist members of the nursing profession the NHS of tomorrow rapidly approaches. Under proposed ‘unscheduled care’ changes from the DoH the first part of this scenario (NHS Direct and Paramedic practioners) will be the main ‘access’ route the NHS. Some units are already replacing their doctors with ‘assessment nurses’ who do the initial ‘clerk-in’ of patients. Surgical, Anaesthetic and Critical Care practioners are already in training. Some hospitals already have ‘line insertion nurses’.

The government are insisting of ‘patient choice’ it’s a shame that choice doesn’t seem to include being seen by a doctor.


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