Nurses to take over from GPs on home visits

NURSES are set to replace doctors on many out-of-hours home visits under plans being considered by the Scottish government to address the chronic shortage of GPs available for night and weekend working.

Ministers believe nurses could be used instead of doctors for many cases when a home visit is judged necessary but the patient's condition is not causing particular alarm.

The move is being considered in the wake of a damning report into NHS out-of-hours care by Audit Scotland that showed a huge drop in the number of doctors working night shifts.

Last night, a Scottish government source admitted nurses had already begun attending home visits for minor complaints and that was expected to increase significantly in the next few years.

But the move was met with alarm by patients' groups, which described the development as "dangerous".

Traditionally, doctors have been on call to attend patients who take ill during the night, and this has continued despite huge changes to the NHS out-of-hours service.

Previously, a patient would ring his or her local surgery to request an emergency visit. But now NHS 24 staff will recommend a home visit in cases when it is difficult for a patient to attend a primary care emergency centre but the condition is not considered life-threatening enough for an ambulance.

Despite the expansion of out-of-hours call centres and clinics, there are still thousands of home visits across Scotland every year, usually to the elderly or the very young. The source said: "Some nurses are trained to a high level and can dispense prescriptions. They are already doing some degree of out-of-hours work, such as changing a dressing.

"They are qualified to a degree where they can make an assessment of the patient. And they can call on the advice of a doctor if they need it.

"If it was a complicated problem, the nurse would have the professional knowledge to make a judgment that the patient would require a doctor or hospital."

The source added: "The Health Minister has already said we do need to look at using other people with medical training to fill the gaps if we don't have GPs doing that work."

Ann Thomson, deputy director of the Royal College of Nursing in Scotland, welcomed the move.

She said: "This is something nurses could do. They already go out into the community during the day. A nurse could go out and assess the patient and decide what care is required.

"It is not a cheap option. It's about delivering a better service for patients and using healthcare professionals in a much smarter and better way."

But Dr Robbie Robertson, secretary of the Scotland Patients Association, said he had serious reservations. He said: "There will be times when nurses have to do things that only a doctor is trained to do in emergencies. I think the nurses would need to be highly experienced, because they are going to be on their own in someone's house and, unless they have had some sort of paramedic training, it could be a very dangerous situation.

"There is an element of risk, as there may be times when the problem is complex, such as abdominal pain, when they will really have to know what they are doing. Something like appendicitis can be missed quite easily. I can understand where the nurses are coming from in wanting to do this, but are they experienced enough? That is my concern."

Last week's Audit Scotland report warned of a crisis in the out-of-hours healthcare system because of the shortage of GPs working at night and at weekends.

Since a new contract in 2004 allowed GPs to opt out of providing cover at night and at the weekends, the number willing to do such shifts has dropped from almost 1,700 in 2004-5 to 1,440 in 2006-7.

The number of nurses providing care in out-of-hours clinics has increased to take up the slack in the system, and many specially qualified nurses can diagnose illnesses and prescribe medication.

Dr Dean Marshall, chairman of the BMA's Scottish GP committee, said: "Nurses are very good at what they do but they can't completely replace GPs. There is definitely a place for nurses working out-of-hours. But doctors do still want to work night shifts and I am worried that we will move completely away from this."

All in a night's work for health staff

IT'S just after midnight when the Bingham family arrive in the waiting room of Wallacetown Health Centre, Dundee, with their seven-month-old baby.

Anthony and Nicola are anxious about their son, who has been vomiting all evening and has been ill for two days.

They had already visited their GP that day and been told to keep an eye on baby Anthony, but things are getting worse.

Like many parents, they had phoned NHS 24 and been directed to their local out-of-hours clinic. They are seen almost immediately by Dr Tom Campion who, after a thorough examination and medical history, says he is happy to send the family home because Anthony is bright and alert and not showing signs of dehydration. But they are also given the clinic's direct line in case things get worse.

The same number is handed to Ade and Dupe Omotosho, whose 15-month-old son Damilola is in pain and discomfort but otherwise is found to have no alarming symptoms. Their time with medical staff in the early hours of Saturday morning is typical of that of many patients, usually the very young or the very old, whose symptoms become worrying when their own GP has closed his or her doors.

NHS Tayside's out-of-hours service at Wallacetown Health Centre provides an extensive service for patients all over the region and sometimes beyond.

The building hosts a 24-hour NHS call centre whose staff assess someone's condition. If a patient needs to be seen by a doctor, but is not a 999 emergency, the call is transferred to the clinic's 'hub', where nurses have maps and information at their disposal and send doctors out or invite patients in. Many arrive still wearing their slippers in their haste to be seen.

On the Friday to Saturday shift, to which Scotland on Sunday was given unprecedented access, staff dealt with dozens of patients, from sick babies such as Anthony to suicide threats. Calls are put through to staff specially trained to deal with a particular problem, and the centre has doctors, nurses and psychiatric experts.

With such antisocial hours and such challenging but usually non life-threatening situations faced every night, why do doctors and nurses do this work?

Dr Sebastian Miller, one of two doctors on duty on the Friday to Saturday overnight shift and a full-time out-of-hours GP, says he enjoys the fact that it is "old-fashioned medicine".

He adds: "It is more like basic medicine. General practice during the day is more about management of chronic diseases."

Miller has had three house calls in Dundee before midnight. "I had a man with hip pain and a lady with a urine infection who was becoming confused. I needed to talk to her family and tell them what to do. We also had a girl, aged six, with an asthma attack but she responded quickly to the nebuliser."

The manager in charge of the service is medical director GP Joyce Meikle.

She is proud of her staff and the help they provide, and while the patients seen on this shift were all in need of urgent attention, Meikle is concerned about a growing number who she believes use it because it is convenient.

She says: "The majority of patients use the service properly and have a genuine need to be seen out of hours. However, there is an increasing minority who come because it is convenient and for whatever reason can't see a GP at the time they want during the day."