Hear no evil
The NHS is trying to create more ways to let you be treated without a doctor being involved. But does it work? Is it efficient? And do those involved understand the system they are operating?
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Hear no evil
The various systems the NHS uses can be complicated. Over the past five years it has sometimes felt as if the service is lurching from one crisis to the next. Take the GP crisis, for instance. We start with too few doctors, so we train more, meanwhile asking pharmacists and various grades of nurses to step in and help with the basics, and suddenly we have a slew of newly qualified doctors who can’t get jobs.
We are also left with a system that can, on occasion, not only prove chaotic, but also ruthlessly inefficient. The following experience of a patient in north east Somerset illustrates just how badly the system can go wrong.
It was between Christmas and New Year and the patient needed ear spray (his personal view) for an outer ear infection. As he was aware this was exactly the sort of thing that pharmacists are now supposed to be able to help with, he popped in to see his local one.
Here, he was told by the sales assistant that the pharmacist could only examine him if he was under 17. He wasn’t.
Nevertheless, the pharmacist had overheard the conversation and said he’d see the patient anyway. How this works if the rule is really a rule, we are not quite sure. Our patient, however was grateful. The pharmacist confirmed it was a minor, if irritating, ear infection.
Although he felt able to examine the patient, the pharmacist told him that he was unable to prescribe anything. Instead the patient should telephone 111 and get help there from the telephone GP service.
The 111 service in Somerset has had its problems, so it did not surprise our patient that it took an hour to get an answer, what with the call waiting time and the eventual consultation.
The answer he received? “Why are you calling 111, the pharmacist should be able to help.” However, instead of suggesting the patient went back to the pharmacist, he was told to go to his nearest Minor Injury Unit (MIU).
Here the patient had to wait an hour as, quite rightly, other patients with more serious and urgent problems were prioritised. After an hour, he got to see an Advanced Nurse Practitioner (ANP). He also looked at the ear and identified the infection, just as the pharmacist had before and prescribed Otomize.
The patient asked if he could get this at the pharmacy attached to the MIU, but was told no, because “we don’t have it in stock”. Sensing a potential problem, the patient asked if maybe the ANP could prescribe a generic.
No, he was told, Otomize is fine and they stock it at the local supermarket pharmacy.
Inevitably, as you no doubt anticipate, the supermarket pharmacy did not have it in stock. They referred the patient on to what was, by then, the only other pharmacy still open in town
They didn’t have Otomize either and one of their staff helpfully volunteered the fact that it had been unavailable for a couple of months and was out of stock in most places in the area.
Our patient asked if he could simply be given the generic spray instead of the Otomize. It turns out that this is not allowed. Because the Nurse Practitioner had insisted on prescribing a brand, no pharmacist, he was told, would be allowed to replace it with a generic.
Our patient now called the MIU again and asked if the prescription could be amended and a new one put on the system, so the pharmacy he was in could access it.
The triage nurse at the MIU told the patient that they could not do that. The patient would need to return to the MIU and be re-examined.
Some frustration was creeping into the phone call and, as the toing and froing continued, the triage nurse eventually agreed to let the patient speak to the ANP again.
The patient asked if they could change the prescription for a generic. The ANP tried, then after about 10 minutes of the patient being on hold, had to admit the system wouldn’t allow it.
At which point the ANP had a moment of inspiration and told the patient that, although they didn’t have a generic spray, they did have generic drops and these had been in their stock the whole time.
Our patient was invited to return to the MIU where he was duly given the drops.
The icing on the cake was still to come. On receiving the drops the patient questioned why he was not being given the prescription charge of £9.90. He was ready and willing to pay.
Instead, he was told the charge only applied to the original prescription which had not been dispensed and did not apply to the new prescription, which had.
The NHS finished up £9.90 out of pocket.
Lots of NHS time was needlessly wasted. From the patient’s point of view, what could have been a five-minute consultation and a few ear drops took over six hours to resolve.
From the NHS’s point of view instead of a five-minute appointment with one GP, the following were all involved:
Three pharmacists
The 111 service
The triage nurse at the MIU
An ANP at the MIU
It is perfectly possible the this story was a one-off. We have not used names and locations as we do not seek to embarrass individuals who were only trying to do their job, suffice it to say all the action took place in Somerset.
But it is certainly indicative of a system that is becoming too complex or at least a system where many of the people in it do not know how it should work.
In this instance at least, the time cost to the NHS as a whole was embarrassingly large and the system hopelessly inefficient.
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This is frightening. What if the patient hadn’t had access to transport? What he hadn’t had the confidence or capacity to pursue the absurdity of it all without becoming openly angry? Perhaps what is missing is the diagnosing clinician’s responsibility for ensuring their patient can access the prescribed treatment. It’s no one fault but it is a dangerous mess.
The NHS wouldn't function without its "pathways", "processes" and "procedures". Herein lies the vulnerability of its "system".