01 April 2019

Obtaining a good and adequate standard of service is a key principle in the provision of healthcare. Very often we feel relieved when we see the senior member of a team, for example the consultant, rather than one of their team at a hospital appointment. It is often assumed that care provided by the consultant will be the highest level possible.

However, we cannot all get to see the consultant when referred to the hospital and this can raise a question of what level of service is reasonable.

This question has become more relevant following a recent announcement that other, less qualified, practitioners will be recruited to work alongside hard-pressed GPs. [Source – NHS England : January 2019].

New Proposals

NHS England has announced that the new staff will work with GPs who currently take responsibility for some 300 million appointments each year. The practitioners will also provide continuing care to patients in the community. NHS England hopes that this will allow GPs to spend more time with the sickest patients.

This proposal raises a question of the level of service and expertise that can be expected from such “GP Associates”.

NHS England reports that it plans to recruit not doctors, but physios, pharmacists and paramedics to assist GPs in this way. Of course, such staff will not have the same level of training as General Practitioners. Given the suggestion that they are to relieve pressure on the GPs, the question is what level of service can we expect from these other specialisms?

Assessing the Relevant Standard

The same question has arisen in the past in addition to the level of service provided by a trainee doctor. This was considered in the case of Wilsher v Essex Area Health byAuthority [1988]. This case involved the actions of a junior doctor who unfortunately wrongly placed a catheter into a young baby while it was being cared for on the special care baby unit. The baby suffered personal injury. The Court had to assess whether it was below the appropriate standard care, given that the error was an easy mistake to make due to the size of the infant and the inexperience of the doctor. It was argued by the Defendant that this was a level of care which was acceptable in the circumstances.

The Court rejected this argument and stated that junior doctors must adhere to the same standard of care as those who are more senior: everyone working in the unit should exercise the same professional standard, either by their own actions or by looking to a senior colleague for guidance when they see that that the issue is beyond their own expertise or experience.

GP helpers

Clearly, how this principle will apply to the involvement of less qualified staff in GP surgeries will depend on each scenario. If less qualified specialists are placed in a position of making a diagnosis when a patient first presents, the level of service is likely to be assessed on the same basis as in Wilsher v Essex House Authority. Therefore, if the pharmacist, physiotherapist or paramedic is faced with clinical signs and symptoms which are beyond their expertise, they should look to a colleague, often the GP, for a second opinion.

If, however, the GP has already made the working diagnosis, and, for example, requested the involvement of a physiotherapist, the standard of physiotherapy will be assessed against the standard of a reasonably competent physiotherapist, as opposed to the standard of a GP.

It is likely that such specialists will be employees of the GP surgery, in which case the surgery and its GPs will carry responsibility for the actions and decisions of their staff. It is therefore in the GPs’ interests to ensure that sufficient policies and procedures are in place to ensure that a comprehensive and acceptable level of service is provided. In particular, non-GP staff who are brought in must know and understand when to carry on under their own steam and when to insist on advice and input from one of the GP colleagues.

It is clear that there are benefits to be had in using other specialisms in a service under increasing pressure. However, a system that strictly manages the arrangement and controls the level of responsibility and authority is required to ensure patients receive the correct level of service.

If you have any questions or concerns about this topic, please contact Peter Livingstone on 01935 846131 or