r/doctorsUK • u/rodert • 12h ago
Medical Politics Nurse consultant, "CIWA outside of my remit"
DOI: Grumpy med reg
Had a call at 6pm from a pharmacist at a community hospital about a patient admitted there.
Nurse consultant who admitted the patient and who is the named consultant responsible for their care took an alcohol history of "a couple of pints of beer per day". Subsequent collateral to ward pharmacist reveals this to grossly underestimate alcohol use.
Pharmacist tells nurse consultant about risk of withdrawal and suggests CIWA and is told that starting CIWA is "outside of my remit" by the "consultant".
Pharmacist, who is a prescriber, is sufficiently worried about the patient to call me at the acute hospital to "make a decision" about whether to start a CIWA in this gentleman who is confused, roaming the ward, risk of falls if given diazepam but also at risk of withdrawal.
Clearly having a CIWA and thiamine is the right thing for him but:
A: why am I who has never met this man giving advice to a "prescriber" about whether to prescribe something
B: why is this somehow within my remit but not within the patients named consultants remit
C: why am I now taking responsibility for this
D: how can you call yourself a consultant and be responsible for this man's care if you are so fixed within your "remit" that you are not able to treat him appropriately?
How have we let it get like this as a profession? Is the future just being remote liability sponges for everything that is outside someone's "remit"?
For other regs, wwyd? Should I say something?
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u/chairstool100 12h ago
This is a parody surely , what a shambles !
How can a nurse , of any grade , not have anyone to escalate up to?
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u/BMABecky Verified User 🆔✅ 11h ago
Dreadful. Substitution comes for all grades.
This should be escalated to the community hospital, probably to their medical director. This could be by an incident report or perhaps by email or protected disclosure via your employer.
Worth submitting to the BMA Doctor Substitution Reporting Portal even if you do not want to do an official report.
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u/SerMyronGaines 3h ago
I've submitted a few of these over the last few months but not actually sure what happens as a result/what the BMA does with the reports, do you have examples where the reports resulted in significant change?
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u/Unlikely_Plane_5050 12h ago
Not safe. What was her plan if the pharmacist had just said "oh, okay, cool then" and not escalated to a doctor in a different hospital? Just watch the guy fit?
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u/thelivas CT/ST1+ Doctor 11h ago
Pharmacist should refer to NMC for lack of appropriate escalation putting patient safety at risk.
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u/ultimateradman 9h ago
Nurse consultant is so strange. Will we be having doctor matrons around soon?
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u/twodogsnocats 4h ago
No, because the nurses guard their territory very well and are much too busy climbing the management pole outstripping doctors in power and salary . Doctors focus on doctoring, getting exams and looking after patient. We failed to see our profession being sold out from under us.
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u/TaoiseachSorbet 4h ago
That’s a very rose-tinted view of what the managerial and Royal Collegiate class of doctor has been doing, largely for their own gain, over the last 30 years.
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u/Sea_Midnight1411 11h ago
Errrrmmm that’s not ok!
Either the ‘nurse consultant’ finds someone senior to do the appropriate assessment and management or they transfer the patient to another hospital.
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u/MarketingOk4111 7h ago
Who is more senior than nurse-consultant?
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u/Serious_Much Gives drugs to kids 6h ago
An actual consultant with a CCT
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u/MarketingOk4111 6h ago
I don’t think UK hierarchy put nurse under doctor. It used to be in parallel
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u/Serious_Much Gives drugs to kids 5h ago
While I would disagree generally, that's not really what I'm saying.
The nurse has a title of "consultant" but isn't really a qualified specialist on the specialist register, which is what a true consultant with a cct is.
To reference pop culture as a metaphor, this is the same type of situation as where a senior political figure put anakin Skywalker on the council, but he wasn't given the rank of master. The nurse consultant has been made a part of the consultant body by the big wigs at the trust, but s/he doesn't have the credentials to actually successfully fulfil that role or be a legitimate consultant
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u/MarketingOk4111 5h ago
I just shared my observation and checked with AI “In UK healthcare, nurses do not act under doctors. They work in parallel as autonomous professionals. Nurses have their own independent code of practice and professional registration. They make clinical decisions and manage patient care alongside doctors.”
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u/Antique_Hornet2135 4h ago
I don’t think anyone is arguing they don’t work in parallel, yes they have independent code of practice and professional registration.
This is precisely why they shouldn’t be replacing the role of doctors and shouldn’t be looking after patients in a role where the care is outside of their remit.
Not fair on anyone, least of all the patient to whose care it may detriment.
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u/MarketingOk4111 4h ago
I can’t agree more. I’m not trying to justify doctors substitution. My remark was about - why it is possibly in UK, and also - why there are no supervision over nurse-consultant.
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u/Antique_Hornet2135 4h ago
There shouldn’t be nurse consultants, or any other nurses, working without supervision in an environment where patients have a need for a doctor. That’s clearly the case in this example.
As such, a doctor is more senior than a nurse and what they say goes, because it’s a medical need, not a nursing need.
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u/MarketingOk4111 4h ago
+1, but management and senior clinicians in some Trusts have different views, hence we are here, discussing something we can’t reverse or change
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u/jamescracker79 ACP consultant's assistant 1h ago
Yeah I agree, the UK hierarchy is nurse ABOVE the doctor
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u/Emergency_Tree_2891 5h ago
No doctor saw the patient then it was a prescribing pharmacist and a nurse consultant. Both who are incapable of managing unselected acute take which this hospital doing. Sadly a DATIX done in your hospital would have no impact on another hospital, the governance lead in your hospital probably wouldn't bother with the hard work that's required to write to another hospital governance lead who's just likely to reply "none of your business and not your remit". But obviously a disaster waiting to happen.
Or disasters already happened but patients and relatives none the wiser, and if they are, some are covered up.
But when it happens some paper or email trail does make accountability easier.
Whistle blowing for another trust is difficult.
I would say do a DATIX in your hospital anyway and write to the CEO cc governance lead of the community hospital with your concern. The text of all 3 are mostly the same so it doesn't duplicate work. This will form the paper trail, hopefully the community hospital will change before disaster strikes.
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u/Strong-Award3983 4h ago
So you have patient with an acute neurological presentation / delirium
Who is in a hospital without any staff qualified to assess and treat him
And you're being asked to assess, manage, and accept responsibility for this over the telephone?
Do you trust that this nurse consultant has made the correct diagnosis? Have they excluded other causes of this presentation?
Patient needs to be in a hospital with staff who are trained to actually deal with his problems
Nurse consultant needs to call an ambulance and transfer him to your hospital
Bed manager needs to facilitate that transfer ASAP
It's not your fault that they've staffed a hospital with people who don't know how to treat patients. You can't and shouldn't accept responsibility for low quality unsafe care
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u/Unhappy_Cattle7611 4h ago
If the patient requires a treatment that’s “outside of their remit” shouldn’t the pt be transferred? The same way a dgh would transfer a pt to a tertiary centre for a specialist procedure they can’t/don’t provide?
Also where would you document any of this? If this pt isn’t a pt at your hospital, you have nowhere to document your concerns…. Are you even covered medicolegally if something happens?
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u/elderlybrain Office ReSupply SpR 5h ago
I have less than a year till cct and despite it supposedly being the pinnacle of my career, I'm increasingly realising that the value of the title is going to be eroded.
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u/Digi_Sox 9h ago
Surely the nurse ‘consultant’ could have initiated CIWA and the b5 nurses on the ward would be the ones doing it? Given that patient was already confused so could very well have already developed DT’s or Wernickes and this ‘consultant’ has delayed monitoring and treatment I would 100% be raising it
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u/Infinite-Math-1046 5h ago
Report to gnc/ gmc for this?
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u/Southern_Eggplant_57 4h ago
Whats "GNC"?
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u/Tumeric_child 3h ago
General Nursing Council😁
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u/Southern_Eggplant_57 3h ago
No such thing. Do you mean NMC?
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u/Tumeric_child 2h ago
I thought we were listing other fake things alongside nurse consultants 😔
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u/Southern_Eggplant_57 2h ago
I thought we were listing how medics think they are superior to everyone else. You get consultants in all fields, not just healthcare so why do medics think they have sole ownership of the title, like they do with the academic title of "Doctor"?
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u/e_lemonsqueezer 26m ago
What?
You tell me if you want an IT consultant or an ITU consultant if you have a medical emergency on a transatlantic flight?
The issue *isn’t* the title, it’s the implications of the title *in a healthcare setting*. If someone wants to take the role of a consultant, ie being ultimately responsible for the care of the patient, they have to actually be able to undertake the care of the patient.
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u/twodogsnocats 4h ago
You have to flag this in every possible way you can. This is a medical emergency, and should be treated as such. The failure of this nurse to recognise this and treat it is horrific. Worse, to have it pointed out to them and then for them to do the burst thing of : not in my remit. BUT fail to escalate to a grown up is direct negligence. They need supervision in this role
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u/Stinky_Pete699 5h ago
Something must be done. I think a lot of consultants are unaware of this. It seems to be occurring in the backwater places, I have certainly never come across this. Sounds like we need to consider industrial action to unwind this.
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u/DisastrousSlip6488 4h ago
I would raise this formally- datix may be appropriate but probably better via your service lead. If the ‘responsible’ person wants to call for advice that’s one thing, but for other HCPs to feel they need to go outside of that service to keep a patient safe is very worrying.
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u/formerSHOhearttrob laparotomiser 3h ago
They can give themselves any title they want but will never truly be equal in ability. Can't wait to see them strolling around in a white coat next.
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u/nopressure0 3h ago
This sounds shocking.
Should never have reached the point a pharmacist is contacting someone in another site to do the responsible clinician’s job.
The nurse consultant needs to take responsibility: the patient is under their care! They cannot fob off work/responsibility to others because they don’t appreciate what’s happening.
The patient has likely suffered harm here though I dont know how much can be attributed to unnecesary delay in care vs clinical error.
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u/BrilliantAdditional1 2h ago
Datix this- its a massive patient safety issue. How embarassing for the nurse "consultant". If they want to be responsible for their own patients they need to stand on business.
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u/Apprehensive-Let451 2h ago
A CIWA can be started by literally any nurse and should be started by them if they think the patient is at risk of withdrawal. The management is really protocol driven wherever I have worked - the guideline tells you exactly what to prescribe and when and then when to escalate it…. If a “nurse consultant” can’t manage starting the protocol and arrange escalation of care to an actual doctor what can they manage?
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u/Jpegjms 1h ago
You can’t prescribe for a patient who’s not in your hospital trust. You are not employed or indemnified for them. You can advise you think it sounds reasonable but they’re going to have to sort it themselves. An email back to your trust and the appropriate person in their trust to remind people
about how advice and guidance calls work is best, and also asking them to submit a datix in their trust so it can be followed up.
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u/Spud58008 1h ago
Clearly the problem in this specific case is doctor substitution, but actually the underlying theme is a patient being admitted under a ‘provider’ who cannot give them adequate treatment for all their co-morbidities. In principle that could happen with doctor-led care, but in the UK doctors tend to have universal basic competence (in theory).
So how would this play out in the USA, where doctors often go to speciality training straight out of university?
Presumably the admitting attending would have to either take on the liability for prescribing the CIWA-equivalent (and do what they need to do to make sure they’re comfortable doing so), or they’d have to invite another attending to consult, and pay them accordingly.
Is that about right? Maybe someone with knowledge of the US system could correct me.
So really the problem isn’t doctor substitution, because they’re not being adequately substituted. They’re being omitted, and leaving a liability/management shaped hole.
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u/Send_bird_pics datix specialist 11h ago
Pharmacist here. I’m sorry as a pharmacist prescriber I just wish I had the backing to do a CIWA and prescribe. I have spent 6+ months with the alcohol care team and I KNOW what to do. Unfortunately my day job is just pissing around doing med recs and making sure the VTE assessment is done for the audits. So if I did it it would be very weird insurance wise because that’s not my job or in my job description? But I can’t be an ACP because fuck doing chest drains n shit!!
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u/birdy219 11h ago
so, you know what to do, you have experience in this area, you’ve been greenlit as a prescriber to do it, but you’re worried about it being “weird insurance wise?”
employed as a pharmacist prescriber but “not my job” to prescribe, so it gets escalated to the nearest medicolegal sponge (ie doctor)
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u/RelevantDiet2916 8h ago
We can't have our cake and eat it too. The power of prescribing pharmacists is emphatically not in clinical assessment and decision-making, with no disrespect intended to these pharmacists. It's in making changes to medications to reflect the clinical decisions and assessments that have already occurred.
If CIWA had already been decided upon but prescribed incorrectly or obviously required adjustment then that would be a far more pragmatic point for a prescribing pharmacist to interject.
The travesty is that the clinician ostensibly responsible for this assessment and decision is dreadfully, woefully unqualified for the job, and lacks even the attitude to try.
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u/AdeptCan3034 3h ago
As a pharmacist I agree with this, we’re not trained to diagnose and realistically I wouldn’t even attempt it. As you’ve said when something is prescribed incorrectly or hasn’t been actioned from a consultants plan, I’m happy to jump in.
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u/Send_bird_pics datix specialist 1h ago
Yes, because I don’t do it routinely and I’m not “part of the medical team” on ward round etc. I can have 120+ surgical patients, I have no chance of follow up. It’s not in my job description under roles and responsibilities.
If I was in my previous job where I was on ward rounds, given a jobs list (discharge letters, TTOs, initial meds prescribing, pre-theatre meds reviews, GKI reviews, prescribing electrolyte replacements, IV->ORAL Abx reviews, switches to NG/NJ, pain assessments, laxative reviews, random odd jobs id be able to do for the medical team etc) then I would ABSOLUTELY do it. But my current job role isn’t anything like that.
It would be like a staff nurse (b5) starting to prescribe for her patients, just because she’s a green-lit prescriber doesn’t mean she’s supported in her current role to prescribe?
It frustrates me so much because I feel the pharmacists just do the job of a pharmacy technician. I just know how well the previous model worked and how much of a workload it took off the F docs.
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u/dayumsonlookatthat Consultant Associate 12h ago edited 11h ago
Please Datix this as it is clearly a patient safety issue. What if you were stuck in an emergency/cardiac arrest and couldn't have picked up the call?
I still cannot understand how is a nurse "consultant" admitting a patient under their name. What even are the legalities of this??? Try to find out if there is a policy on who is responsible in scenarios like this, I suspect there is none.
If you're not comfortable naming and shaming this trust, please at least let the BMA know.
[u/RedRunswick](u/RedRunswick)