‘DANGEROUS AND UNREGULATED’ – Doctor slams privately run walk-in centres

Mass rally of Royal College of Nursing members in central London on May 11 against cuts in the NHS
Mass rally of Royal College of Nursing members in central London on May 11 against cuts in the NHS

DR Anila Reddy has resigned from his post as the lead GP at an NHS ‘walk-in centre’ run by the private sector, at London’s Canary Wharf.

Dr Reddy has blamed ‘hamfisted politicians’ for ‘making a mess of the NHS’.

‘The bottom line is that in Britain today a nurse after her basic qualification can see any patient that walks in off the street, because there is no legislation stopping her working outside her sphere of competence and experience,’ Dr Reddy told News Line.

The following are extracts from a letter sent by Dr Reddy to the Secretary of State for Health, Patricia Hewitt. The letter begins:

‘Dear Ms. Patricia Hewitt,

‘I am writing this letter in accordance with the GMC guidelines, which make it clear that it is expected of me in my duties as a doctor to bring it to the attention of my superiors, if I become aware of a situation where patient safety is being put at risk.

‘I would expect action to be taken promptly regarding my concerns.

‘I have informed my immediate local managers and they are handling my concerns in a correct and decent manner, but it appears that the patient safety issue I have raised locally is a result of your department’s policies and affects many other privately-run NHS walk-in centres.

‘I am forwarding this letter to the leaders of the medical and nursing professions, the Royal Colleges, the BMA, the GMC and the NMC, in the hope that they are more informed about the present dangerous, relatively unregulated situation which has become apparent in the rush to implement the new nurse-led walk-in centres.’

Dr Reddy adds: ‘As a doctor I have a duty to be an effective advocate for patient safety.

‘I have resolved to go to the European Court if I do not see some attempt at resolving the issues I am about to raise. . .

‘I am a UK-born, Aberdeen-trained General Practitioner, with post-graduate training in Medicine and Paediatrics, and I have a wide range of post-graduate qualifications and experience in various specialities, and therefore would respectfully ask that you consider the issues I am raising.

‘My sound training in Scotland undoubtedly taught me to stand up if something is wrong and to uphold the spirit of “primum non nocere’’ (“foremost do no harm’’).

‘I have, for the first time in my life, resigned from my post as a doctor.

‘To be fair to my employers, this was over the fact that an inexperienced nurse manager was being put in charge of clinical issues in preference to the doctor.

‘But I was also very unhappy with the potential dangers to patients that the new system will cause.

‘I have been the lead GP working for Atos Origin, a post I have had for the last four months in one of the new, privately-run commuter NHS walk-in centres at Canary Wharf.

‘This centre is now caring for a large under-privileged population on the Isle Of Dogs, as well as commuters, and will soon be seeing up to 100 patients per day of bread and butter GP-type patients – not the envisaged illusory minor illness group, but a wide range of acutely unwell patients.

‘This centre is now an overflow for the local GP practices and it is of note that some of the PCT-run local practices have a two-week waiting list for emergency appointments.’

Dr Reddy’s letter goes on to say: ‘There are three issues I wish to highlight regarding the privately-run NHS walk-in centres.

‘At present, there are presently four out of the 76 nurse-led NHS walk-in centres that are managed by private companies, but with plans for expansion of this scheme by the Department of Health.

‘These plans should be stopped until the implementation of this new kind of centre is well planned, otherwise patients are suffering and will suffer.

‘Firstly,’ writes Dr Reddy, ‘the advice by the Department of Health to these private companies that the nurses they employ do not need to follow written protocols. . .

‘I have been assured by Ms. Valerie Smith, the Independent Sector Advisor for the RCN, that the walk-in centres should have protocols.

‘In the 72 NHS-run NHS walk-in centres, they all have PGDs and/or nurse prescribers.

‘They all have clinical assessment support systems, whether this is IT or manual, folder-based.

‘This is not the case for the private NHS walk-in centres. . .

‘Also, the advice to them that the unit GP only needs to be present in the unit for one hour a day, even when there are dependent nurses seeing patients in the unit, is totally inappropriate.

‘The doctor should be there all the time if nurses are going out of their sphere of competence.

‘Secondly,’ Dr Reddy says, ‘I would like to expose the lack of any clear method for the independent objective assessment of a nurse’s competency to see, assess and treat patients suffering from the wide range of complaints seen in General Practice.

‘The individual nurse makes a very subjective assessment of her own competency to decide if it is suitable for her to see a particular patient.

‘This is ridiculously loose and dangerous.

‘In training to be a doctor one is continually, on a daily basis, being assessed on our history-taking and examination skills.

‘These are further tested by rigorous undergraduate and post-graduate examinations. . .

‘The nurses now are seeing the same patients we do.

‘I have been staggered by the lack of regulation of the nurse practitioners in the private centre in which I was working.

‘There are many types of nurses that seemingly can be employed in these centres, from district nurses to nursing home nurses.

‘The third issue,’ Dr Reddy adds, ‘is the fact that different types of nurses are being employed in senior management roles and as clinicians, with no national standards being in place as regards to the knowledge, skills or experience of the nurse recruited to these units.

‘This is bizarre when one sees they are being allowed to deal with sick people.

‘They are overtly working out of their spheres of competence.

‘But this is because the sphere of competence has not been adequately defined.

‘There are emergency practitioners employed, who are often not trained in minor illness, and many of the nurses who are trained in minor illness have little trauma experience.

‘The district nurses employed are similarly not skilled in minor illness.

‘In my centre, none of the nurses are paediatrically registered with the NMC, yet seem to be able to assess children. . . .

‘It would be incredible if it was said that it was okay for any doctor to examine a child or baby because there was a paediatrician in the hospital. . .

‘People not adequately trained are a danger to babies, children, mental health patients, eye patients, pregnant and gynaecological patients and, in fact, any patient.

‘The NMC must address this area immediately.

‘I would tactfully suggest it is up to the Royal Colleges to set standards for all practitioners working in their speciality, because this is not happening and the nurse clinician is being rushed in an unsafe manner into a new role by the Department of Health.

‘Patients will be put at risk and it is paramount that the 20-minute minimum waiting time contractual obligation does not lead to nurses over-estimating their competency, or their employers encouraging them not to use protocols so that they will see more categories of patients more quickly.

‘It is of note that I have discussed the situation with Elaine Egad Morris, the National Co-ordinator for the Walk-in Centre Implementation Scheme, and she has told me that she was not allowed to advise these private walk-in centres, despite her team having the necessary expertise.

‘She is as equally flabbergasted as me as to the lack of regulation of these new centres.

‘It should be obvious that managing minor illness well, by its very nature, means being able to detect more serious illness masquerading as minor illness.

‘I ask you all to consider what is meant by being qualified to see a patient.

‘Not treating also has potential serious consequences and where is the logic in saying there is a doctor in the building.

‘That will not stop an inadequately-trained nurse from missing a diagnostic sign.

‘I have done some clinical teaching and the nurses in this unit are less well trained clinically than medical students. That is a fact.

‘Nurse clinicians, whether dependant or independent, are at the moment such a mixed bag that I can say with no offence meant to their potential skills, that nurses do not have sufficient skills to exclude major illness masquerading as minor illness, and people will die.’

Dr Reddy adds: ‘When I was a paediatric registrar, I would always review a junior doctor’s examination findings and diagnosis, until they had worked on that unit for at least three months, and these are people who are much more skilled with a stethoscope.

‘How, after a few days’ training, are you letting these same patients be seen in such an unregulated fashion by people with such a short period of training?

‘A nurse in her pre-graduation training is not routinely using the stethoscope or hand as a diagnostic tool.

‘Surely the standards of assessment must be at least as rigorous as that applied to doctors.

‘The fact is that children and babies are being assessed by nurses who have never worked in paediatrics, or have had a very rudimentary instruction in how to assess children, when a GP has had an obligation to work after graduating on a paediatric ward with babies and children, as part of a three-year vocational scheme, and now is virtually obliged to take the MRCGP.

‘Nurses do need to use protocols for assessment, diagnosis and treatment of patients.

‘I have confirmed this with the senior nurses in the RCN.

‘They have been given leave to use NICE guidelines and Prodigy guidelines off the internet as an unvalidated alternative.

‘This decision is highly dangerous.

‘The inadequacy of definition of the independent and dependent nurse clinician is frankly what one would expect in a poor Third World situation with very poor regulators.

‘There appears to be lack of consensus between the NMC, RCN and the government on what is adequate training for nurse practitioners, and the new walk-in centres are exploiting this lack of definition of standards.

‘Please address this immediately, because patients are at risk today.

‘It is irresponsible of Her Majesty’s Government to implement change in such a cavalier manner.’