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Commentary from RCGP
  1. T Ambury

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    This is a timely call for the standardisation of the training for and the provision of immediate care. The current situation – that such a fundamental service consists of a plethora of providers and skills funded, in the main, through charitable means – is scandalous. Standardised training leading to a quality assured service is in the best interests of patient safety.

    The Royal College of General Practitioners (RCGP) stance is that there must always be a role for doctors in the provision or immediate and unscheduled care, and that all practitioners involved in such care be appropriately trained to national standards. The authors’ call for regulation leading to the “timely intervention of a competent specialist” is one the College welcomes.

    Mackenzie and Bevan speak of raising the standard of the pre-hospital environment to that of at least A&E by citing the latter’s predominantly consultant led status. While true, consultant led does not necessarily mean doctor led. There are now several nurse consultants across the UK, and training is underway to deliver consultant emergency care practitioners (ECP). To imply that paramedic or technician led care may be sub-standard is offensive and also flies in the face of current workforce planning.

    The pre-hospital environment needs a team of competent clinicians providing a pool of skills and experience. Rather than reinforcing existing professional silos by creating a doctor led Faculty of Pre-Hospital and Retrieval medicine, the authors would do better to call for the development of a multi-disciplinary system, with shared training measured against national standards, and workforce planning, to ensure that patients’ needs are well served.

    There is also confusion about provision of such care under the new GMS contract by commissioning of enhanced services by primary care organisations (PCOs). Such commissioning will drive standards of care upwards by making training for, and ongoing competence in, immediate care conform to a set minimum standard. However, PCOs are not restricted to commissioning these services from GPs. Indeed, the flexibility of the enhanced service framework is that it should allow the development of teams of skilled practitioners, including GPs, in the way alluded to above.

    General practitioners with a specialist interest (GPwSI) are, first and foremost, GPs. Guidance to PCOs and other prospective employers regarding the level of skills acquired by GPwSI is designed to ensure that the GP, while working from a generalist position, has attained, and takes steps to maintain, specialist experience and skills. It is likely that appraisal and revalidation will lead to a robust system of ensuring that this does indeed occur. There are as yet no definitive plans for a GP register to be set up, let alone sub-specialist registers below this.

    Therefore, rather than call for the creation of a sub-specialty that maintains the status quo, patients would be better served if a pre-hospital and retrieval medicine speciality was much more ambitious. The Faculty of Pre-Hospital Care should oversee the development of a multi-skilled, multi-disciplinary team of clinicians – medical, nursing and paramedical – to provide care in this setting, working to do so not only with the RCGP, Faculty of Accident and Emergency Medicine, and BASICS, but also nursing and ambulance authorities.


    Thanks to I Maconochie, A&E Consultant, St Mary’s Hospital, London, for discussing an early draft.

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    • Competing interests: none declared

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