By the time you read this, UK health departments may have changed their swine flu guidance to the public and healthcare professionals yet again, if the confusion about the risks to pregnant women over the weekend of 18 to 19 July is anything to go by.
As GPs we find ourselves in the usual minefield of adhering to protocols while trying to act in the best interest of our patients. Writing this on 20 July, the guidance on H1N1 from the DoH was telephone triage of suspected cases, and commencement of treatment.
This is a logical approach, but it is where the problems for clinicians begin. How appropriate and clinically sound is a diagnosis based solely on a telephone conversation? Potentially millions of people could phone us.
The diagnostic criterion is such that we will often be left to decide whether, on the balance of probability, someone has swine flu because of the relatively soft symptoms involved.
A history of fever is particularly problematic as clinical experience shows us that reported fever and actual fever are often very different things. Before H1N1, patients with similar symptoms phoning for advice would most likely have been advised to try symptomatic relief or invited for a face-to-face consultation for assessment.
Now, many patients with similar symptoms are being treated with anti-virals based on phone diagnosis. This is a precarious situation - and one where tragedy seems almost inevitable.
Medical defence organisations advise that telephone diagnosis is not ideal. In the pre-H1N1 era, how often would we begin treatment on a child with history of fever plus two symptoms based purely on a phone consultation?
GPs are missing out on the subtle nuances of the consultation room, and cannot use that vital skill of recognising a child 'just doesn't look right'. The toxic combination of increased time pressures created by demand, and the need for phone consultations increase the risk of misdiagnosis, and increase the pressures felt by clinicians.
My concern is for the poor individuals, who are desperately trying to work in an almost impossible situation, who end up getting caught out by 'meningitis in swine's clothing'.
Vital support mechanisms
Years of training and relationship building, not to mention the impact on them personally, could be destroyed by not having the vital support mechanisms in place.
Health secretary Andy Burnham's activation of the National Flu Pandemic Service (NFPS) in England is a start to alleviating the situation. This service's remit is to treat patients who are un-likely to develop complications.
But it advises high-risk patients to contact their surgery for advice and treatment. A brief review of 'high-risk patients' (over 65 or diabetic or with CKD to mention a few categories) reveals the scale of numbers.
The patients at the highest risk, the most challenging to treat, and the most likely to develop side effects are to be managed by their GP. In other words, the usual fudge, rather than fix.
What we need is effective local management of the problem, such as dedicated local swine flu centres where patients can be assessed properly, rather than leaving individual surgeries to sink under a barrage of work. The same centres could then be used to help co-ordinate the massive task of the swine flu immunisation programme.
Clinicians are under increasing pressures that are forecast to get a lot worse in the coming weeks. Telephone diagnosis is riddled with clinical risk and will prove untenable. If the DoH is going to tackle the H1N1 pandemic effectively, it must put into place a strategic response.
Expecting GP practices to shoulder most of the responsibility is not good for anyone.
- Dr Bunstone is a salaried GP in Cheshire
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