Risk to public safety

One of the distinguishing features of general practice care, compared with secondary care, is the undifferentiated nature of the problems presented by patients (The Ki g s Fund 2010). Patients present to practice with symptoms which are often only partly developed or at an early stage in a disease process. Some of these symptoms may indeed relate to minor illness, but some may not, and it is the detection of the more serious underlying processes which represents the major risk associated with medical and nursing practice.

Minor illness, the demand, definition and management was a presence throughout the i te ie s. Cla e as s athi g of u ses ho o l a aged i o ill ess, othe s, like Ellie and Dawn recognised it as a major part of their role. Minor illness defines a

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multitude of uncomplicated, usually self-limiting illnesses which in most cases would resolve without any intervention. Generally, when the minor illness service is first established GPs and nurses together establish a list of minor ailments which can be booked into a nurse appointment. That list can vary but a common list of presentations as defined by The Ki g s Fu d b) is appended (appendix 9). Some of the nurses interviewed felt confident managing all of these, but many did not, for example, Sandra admitted she would not manage any mental health problems but would refer all of these to her GP colleague.

The inherent risk in treating minor illness is that alarm symptoms may be missed. Some of the symptoms presented in appendix nine can herald major disease (for example, cough, abdominal pain or headache). It is the task of the clinician to

a gi alise the da ge p hi h e ui es GPs or substituting clinicians to have the skills and experience to separate the minority of patients who actually have acute, threatening illness from the majority who have minor or self-limiting illness (The Kings fund 2010b). Some alarm symptoms also form the basis of the two week rule for urgent referral of patients suspected of having cancer; these may include symptoms such as suspicious changes in a skin lesion, alteration in bowel habit or abnormal weight loss. In addition it is important that the clinician can identify and correctly manage acute exacerbations of long term conditions, for example, breathlessness could be related to an infective exacerbation of COPD but also to heart failure.

The issue of clinical risk here is twofold. Defining minor illness as a separate entity, corralling patients into minor illness clinics and using nurses with in-house or modular training to manage this tranche of acute work is clearly attractive to general practice a d has suppo t i the hie a h of e pe tise Cha les-Jones et al 2003). Utilising GPs to manage every viral illness, rash or muscle strain which presents to practice appears to be a poor use of their higher order skills. Claire considered it to be a poor use of her skills also and rarely consulted with patients presenting with minor illness, leaving this work to the practice nurses. But the inherent risk, as described above, is that nurses only trained to manage minor illness presentations might miss the alarm symptoms when they present and as a consequence may reassure and discharge patients who have more serious disease.

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Inevitably in clinical practice mistakes will be made. Evidence from the Medical Defence Union (MDU), an organisation which provides indemnity for general practitioners and their staff, demonstrates an increase in litigation against nurse practitioners. The MDU report that in 2015 there were 25 allegations of clinical negligence against nurse practitioners with one settled for over two million pounds. Most of the allegations concern missed diagnosis, delay in referral and prescribing errors, all critical aspects of their extended practice. Whilst the number appears small in comparison to claims against GPs, they are rising steeply year on year (MDU 2016). It is an NMC requirement that nurses have indemnity relevant to their scope of

practice and traditionally this had been p o ided u si g s ep ese tati e body, the RCN. However in 2012, in a climate of increasing risk and litigation and with

unregulated, fluid and far reaching scope of practice the RCN cynically withdrew professional indemnity protection for nurses working in general practice, insisting it was an employer or personal responsibility (Knight 2012).

For practices using NPs in a different way, managing undifferentiated presentations and sharing the workload more equitably as occurred in Ga o s p a ti e a d fo Jane, working alongside the GPs in walk-in clinics, the risk may be different. It has been demonstrated in a number of studies that NPs refer more and investigate more than GP colleagues (Venning et al 2000, Horrocks et al 2002), possibly because they do not have the same level of training or are more risk averse. The result of this, other than the obvious increased use of costly resources could be heightened patient anxiety as a result of unnecessary and potential invasive or risky procedures. It should be noted that these studies are dated but research has not revisited this as NPs became embedded in the system and more experienced in managing health problems.

As discussed, working within a defined and regulated scope of practice provides some public protection but working beyond it increases risk to both the public and the practitioner. Issues arose not just because nurses felt they were unable to work to the limits of their training and competency but also because they were asked to work beyond it. Sandra described inherently unsafe practices when she was asked to see additional patients in an afternoon surgery when there was no GP in the building; Barbara and Jane dropping in and out of practice nursing duties as required knowing

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this is a highly specialised role requiring current knowledge of policies and treatments and Mandy who remarked on the problem of having patients inappropriately allocated to her instead of the GP when there were no GP appointments available.