Bureaucracy vs Reality

Just before closing time, the mother of a 14 year-old girl phones us and is very anxious about her daughter's "funny breathing" and chest pains that she had had all day at school. She is asked to bring daughter to surgery where GP examines the lass. As a result of the examination, the GP decides that there is no cause for alarm and that with the medication prescribed, she should soon be well again. However, if Mum is at all worried during the night, then she should not hesitate to call the out-of-hours service.

On the way home - GP is giving me a lift to the station - he says that he won't be at all surprised if Mum calls the OOH doctor although as far as he could tell, there was no cause for alarm. We then talked about the uncertainty inherent in many GP diagnoses and the "ninty-nine times in a hundred" they would be correct. Especially in today's medico-legal climate that leaves me worrying about the other "one in a hundred". I reflected on the two different approaches to such a dilemma: the doctor's versus the manager's.

The GP knows that if he or she refused to take probability into account, our hospitals and emergency services would be overwhelmed within a day. He/she takes responsibility for managing the flow of patients to the next stage of medical intervention be it hospital treatment, medication, or perhaps diagnostic testing. It doesn't get noticed because it isn't a tangible activity; but it is a real benefit of having a well-trained and well-motivated "gate keeper".

The manager is likely to try to remove all risk, if not from the system, at least from that part of it for which he is responsible. His approach will be: "if in doubt, refer". I have some sympathy. After all, he is the one that will have to deal with the "one in a hundred" should it result in a formal complaint.

I don't have a neat solution. Homo Sapiens rather inconveniently presents in an infinite variety of shapes, sizes and combination of physical and psychological variations, most of which are tucked away out of sight or reach.

The NHS only works because doctors assess probabilities and having done so, hope for the best. You may not like the sound of that, but in essence, this is what happens. We can rightly demand that this assessment is skilled, appropriate and that the evidence supports the conclusions that are then drawn. If the assessment is proven to be deficient, then let justice prevail. But, providing it is reasonable, our society and its legal processes should support such doctors and resist the demands of those seeking perfection. The costs to us all would be catastrophic.