To think the new “Jess’s rule” should be blindly obvious & it’s an embarrassment that we have to remind GPs this?

[Waitingforthesunnydays]

This new NHS initiative, “Jess’s rule” is supposed to remind GPs to “rethink” things if a patient has had 3 appointments and they haven’t been able to diagnose them with anything. AIBU to think this should be blindingly bloody obvious?! And it’s actually embarrassing that we’re putting up posters to “remind” GPs to get a second opinion or refer on for tests if someone’s had 3 appointments with severe symptoms and hasn’t got a diagnosis. The initiative is a result of the death of Jessica Brady, who was 27 & died of cancer that was missed by GPs in December 2020. She had 20 appointments with SIX different GPs at the same surgery. She was suffering from unexplained weight loss, vomiting, and night sweats which were steadily & significantly worsening. Yet she was told she had long covid (even I know these are not the symptoms of long covid) and was “too young” for cancer. She eventually paid for a private doctor who diagnosed the cancer but by that time it was too late, it had spread and she died 3 weeks later. Am I missing something by thinking these GPs are 100% personally at fault for missing this? Wouldn’t anyone in their right mind think to refer her for further tests if she’d had 20 appointments with six different GPs and her symptoms were severe and getting worse?! Apparently none of the individual GPs have been blamed or investigated at all. It’s being seen as a wider issue with the NHS in general - I really disagree that it is. I can’t imagine going to my gp 20 times and never being referred for further tests. AIBU to think this gp practice is the one at fault here and some disciplinary action needs to be going on?

I disagree. My dad never went to the doctors, but when he did eventually go with abdominal symptoms, he went 6 times over a year. He was told he probably had gastrointestinal upset after a recent holiday in Kenya. It took a visit to A&E to discover he was days away from a completely blocked bowel due to cancer and had emergency surgery. He was told he that had his bowel become completely obstructed he would have died quickly. His cancer had begun to spread by this point though, and it eventually killed him. Who knows if he could have survived it had he had tests the first time he went to his GP?

'their own self-evaluation' isn't the same as 'an investigation,' though.

Yes they do have internal discussions around certain events, but that wouldn't necessarily be called an investigation or result in 'blame', usually the aim is reflection, learning and improvement. As you say, the fact that this resulted in a press campaign and reiteration of referral rules suggest there WAS some sort of analysis/consideration, otherwise we wouldn't be discussing it!

Which was why I asked what the pp meant by "Apparently none of the individual GPs have been blamed or investigated at all," or how she even knows that?

In all actuality it seems like there WAS probably some sort of investigation but because whatever article the OP read didn't say 'and Dr X has been found GUILTY and is going to be tarred and feathered in the town square today" she's assumed this means "none of the individual GPs have been blamed or investigated at all."

Whereas in fact it could mean an investigation is ongoing (and thus can't be shared), or the surgery as a whole was investigated and learning found/recommendations made, but no wrong doing identified by individual GPs, or wrong-doing was identified but because staff disciplinary measures short of being suspended/struck off are (and should be) private it wasn't mentioned...

It should be a simple matter of maths/statistics that appointments above a certain number for the same (or worsening) symptoms should be flagged. You don't need any medical knowledge to understand that something was going wrong here, but you do need a system in place so this sort of thing isn't missed by patients not seeing the same GP and, as a PP said, the dots not being joined up. That could be dealt with by, for example, the practice manager.

None of which is to say that the GPs were not at fault, just that an automated system should have been implemented to catch this in order to insure against human error.

My own experience is that some GPs are bloody useless and seem surprisingly dim considering the qualifications you need to do a medical degree. Others give the impression of not GAF.

I’ve said this before but GP’s only care about dishing out medication. They only know what medicine to give you, not what’s causing it

As a cancer nurse for teens and adolescents, and having seen horrific late presentations, unfortunately this is 100% needed. In fairness, GPs will see hundreds of young people with a sports related injury and 99.9% will just be musculoskeletal. Unfortunately there will be a small number for whom it will be a sarcoma (for instance). 16-24 yo represent 0.6% of cancer diagnosis. I think also people no longer having a named GP that sees them stops professionals from recognising repeated presentations. Anything that raises awareness or enables GPs to seek further investigations is a good thing

I think my use of “self evaluation” suggests an informal or easy process. What actually happens is an independent review, which can recommend changes to practise, disciplinary or fitness to practice procedures for the practitioners involved. It’s not a discussion or reflection session, it’s pretty rigorous and in some cases the outcome will be made public.

I don’t need practitioners to be tarred and feathered in the public square, I do need to know that there is oversight, and that issues are considered and properly addressed - I don’t think that is too much to ask and is consistent with any other regulated profession.

People view medics as specialists and rely on their advice, and getting it wrong costs lives. Yes that means it’s a highly demanding, stressful role, it also means scrutiny is more important because most lay people don’t know enough to be able to hold them to account.

I think it also depends on the trust. My ds has had recurrent tonsillitis (10 times since summer). He did get an ENT appointment fairly quickly after his second hospital admission for it in 4 months.)

Consultant literally said had he been seen in the neighbouring trust, they would have removed them but seeing as I was under our trust (4 miles closer to the hospital of the neighbouring trust, they would have to wait until he is 2. Transferring the referral would delay things in her opinion. He is 2 in March so hopefully will be removed soon.

I think it’s disgusting the level of care you receive is based on a postcode lottery.

I hear what you’re saying but really wouldn’t you refer someone with multiple appointments, weight loss and night sweats? Whatever their age?

It’s not going to change overnight. We’ve had too many years of insufficient training posts. It will take a while to turn things around. Meantime people need to go to the pharmacy with minor issues and reduce the pressure on GPs.

My GP practice seems to be staffed by doctors each working 1 day a week, so it's usually a different person each time, and they don't read back over the previous notes. I know this because I needed a specific letter and they kept writing an incorrect one each time, each one missing out key details discussed with at a previous appointment with a different GP. Surely going back over the patient's notes before an appointment is basic GP stuff?

ETA: other countries don't all have GPs as the gatekeepers to speciallist services, the family doctor role is a valuable role, but there should be other access to specialist services without having to pay for private care.

After several misdiagnoses and awful treatment for several medical conditions, I have developed an almost pathological fear of going to the doctors! I’m a health care professional too!! Which prob doesn’t help.

its to determine where th blood is coming from. Is it further up the bowl or very near the exit? As it determines the type of test you get and also how long the waiting time is. A standard colonoscopy referral is nearly 2 years where I live. A positive FIT test and it’s the two weeks wait

Gosh that’s awful. I’m sorry you had to go through that. It’s as though these GPs have zero medial training. Someone with a history of cancer presents with a lump in their neck.. I mean of course that should be checked.

To be fair since my cancer diagnosis the GPs here do seem to be more cautious. I have been sent for scans for chest pain. Rib pain etc. And they always say ‘because of your history’

It’s just a shame care is so inconsistent.

1 in 2 of us will get cancer. Maybe the training new needs to change if doctors appear to not know what even the basic, most obvious signs are. And that yes young people can get cancer.

As a country we are behind many others in terms of diagnosing and treating cancer. Something really needs to be done.

Not necessarily. DH has a complicated health history due to previous cancer and also brain tumour. He’s now on ten different medications a day. The ones prescribed by the team dealing with the brain tumour are monitored with tests, but only on a yearly basis and there’s no way to get to see the consultant outside of that timeframe. The others as result of the cancer that predated the tumour are not monitored in any way and they seem happy he stays on them forever with no oversight. He has recently had pain in his right side (and he is stoic and there’s no way I’d even no about it unless it was really problematic for him) and was initially sent for physio by referral. He was certain it wasn’t muscular but did it all anyway. Did nothing. It is now ongoing for seven months, no improvement. But is now accompanied by extreme fatigue and in the last few weeks an odd amount of hair loss that is apparent in the shower every morning. Obviously not a great set of symptoms. We have wondered if the hair loss could be due to some of the (unmonitored) drugs he’s on but in conjunction with the other symptoms obviously want it checked. He did an Econsult - detailing symptoms and also his history. He got a one line response from the GP - “The NHS doesn’t deal with hair loss”.
I was genuinely gobsmacked, and we’re old hands at dealing with the NHS.
Anyway, suffice to say after insisting on a second consult he has now been referred for XRay and bloods. Even then because the GP queried ‘broken rib?’ And didn’t add the other symptoms (ie fatigue) the XRay department sent him away and said they don’t treat broken ribs - so another trip to the GP to get the correct form filled and back to the queue.

I am assertive and confident (I’m down as carer btw) so we’re going to get this sorted but the toing and froing is sometimes exhausting (not the first time this sort of thing happened throughout his care). But I imagine plenty of less vocal people, with no one else to advocate for them, would have gone home and left it.

GP's (and sometimes those further up the food chain) have been misdiagnosing cancer for decades upon decades due to malpractice. With absolutely no consequences. Governance and oversight from the GMC is practically non existent.

My friend has had a different response from GP. He has cancer, has had it for some years. He sees his consultant every three months. Anything he attends GP for (he had a rash, not at all related to cancer, pharmacist suggested he speak to GP) now the GP won’t touch him at all - any appointment they tell him it’s because of his cancer and he needs to see his consultant. Each time the (absolutely brilliant) consultant has to send the Go a snippy email telling them to do their job and see him as it isn’t related to the cancer. How much time and money is that wasting?

We Have a new GP started at the practice and he’s very good. Now I make sure I see him if I need an appointment. I’d rather wait as he’s the only one that doesn’t fob people off.

I have also been fobbed off and late to diagnose auto immune conditions because I just wasn’t in the usual age bracket so “it won’t be that”…..even though everything I was diagnosed with we had family history for. And go was aware of that as I mentioned it when I went to appointments. It is so frustrating.

I am sorry but the current system at GP surgeries is awful they are quite literally killing people by not providing thorough diagnosis. The 10 to 15 min slot is not long enough and they only want to talk about 1 symptom and not you as a person and consider other symptoms that may be going on concurrently and could indicate a bigger issue.
They often do give antibiotics or antidepressants etc rather than run tests or seek further treatment or assistance.
They are paid well and they knew what they were getting into so that is no excuse however IMO
the entire NHS needs to be dismantled and reestablished with more front line staff and less middle and senior managers.
They missed my mums pancreatic cancer for two years she was diagnosed and died within 3 weeks.
They are dealing with people's lives and often failing.

Partly, but 10 times in three months is a lot , more than once a week.

I can deeply resonate with this experience. My general practitioners have been quite frustrating, as they insist on addressing only one issue per appointment. This narrow focus prevents them from understanding my overall health, leading to missed diagnoses. My iron deficiency went undetected for years, resulting in heart issues that could have been prevented. Oh boy, was I ill. During one appointment, they almost identified the issue, but they only checked my hemoglobin levels. If they had also tested my ferritin levels, everything would have become clear. Ultimately, I conducted my own research online and found that thyroid issues seemed plausible. I printed out a checklist from a thyroid website and went through my symptoms. This is what I gave to the doctor at one appointment, as I felt I was literally dying. That's when a comprehensive Thyroid and iron test was finally conducted.

My brother was seen nearly a dozen times and told he was just run down and needed more sleep. He was eventually seen by a better GP who referred him for a chest xray. So simple and then his cancer was diagnosed.

The home test you get is to look for minute traces of blood in the stool (that you can't notice yourself). My DH was told he couldn't use it one time because he potentially had a tiny amount of blood in there due to another procedure. I guess they may do more of the same test to see if it is consistently there if it comes back positive, but if you are actively bleeding there would seem little point. And if there was no explanation for the bleeding you would want it to be escalated to a colonoscopy or something to see where the bleeding is coming from.

Sorry I can’t make head nor tail of your post, it’s gibberish. But my mum wasn’t referred to anyone by any GP, she got no treatment from them at all. She was told multiple times she had a flu virus, no bloods were taken, no tests, nothing. Sent home on multiple occasions with no action by the GP. By the time she was finally taken seriously by A&E her cancer had advanced so much and now she’s dead. People are allowed to be angry at GPs for not taking any action when someone visits them seriously unwell.

Apologies if English not your first language, I'm not sure why there would be confusion otherwise.

To break it down a bit there was a previous post stating that they thought GPs were diagnosing flu/viral and not referring or giving antibiotics out of laziness, which for anyone working in medicine will know writing a referral is a very simple and easy way of passing the buck to someone else. To put your name to a diagnosis and evidence that decision is more work, more risk.

Unfortunately pretty much all sinister diagnosis will start off vague/mild - tingling hands, a trip, less energy than normal, a headache, a cough. It's just not possible to have a service that picks up 100% - trying to differentiate those that are sinister from the minor illness is the art of medicine.

To refer every single one of those patients would be very simple and easy - if you wanted to be a lazy clinician that's what you would do. Mistakes rarely occur due to laziness and to suggest that's the common denominator shows a complete lack of understanding.

The GPs job is a hard one to pick out the serious from the far more common non serious presentations they see. Sometimes even good GPs will get it wrong and there should always be safety net advice given to come back if it’s worse.

I think what we ask of GP’s is actually impossible, which is why there is such widespread (and justified) dissatisfaction. If I present with changed bowel habits and abdominal pain, the only surefire way to rule out colon cancer is a colonoscopy. We all know this, GP’s must also know this. So presumably they don’t refer on because of resourcing/rationing considerations? If it’s resourcing/rationing preventing that referral, the GP needs to be honest that they can’t rule out the risk of cancer using limited NHS resources, the NHS wait time outside the TWR might be clinically significant if the patient has a malignancy, and if they want peace of mind a private procedure might be the way to go. That at least is honest.

I have a relative who is a registrar (whatever they’re called now) in a famous London hospital, and after waiting however long for a routine MRI, he has patients who have waited another 18 months for the results.

I have lived - and used healthcare - in 3 other countries and I honestly don’t understand why the Brits just accept that there’s a good chance they’ll die early because the NHS cannot cope with demand.

Agree with you that the attitude of reverence to the NHS doesn’t help things!

It is literally an impossible task. Even a colonoscopy cannot rule out bowel cancer 100%. Every test has a false +ve and false -ve rate. Cancers have absolutely been missed on colonoscopy. There is no absolute certainty with any test which is something the general public do not understand. They think that if they only had the right test there would be a correct diagnosis but it’s much more complicated than that.

The pre test probability that a 20 year old’s PR bleeding is due to bowel cancer is much less than that a 50 year olds is. This is a medical fact. Not to say that the 20year old cannot have cancer but the chances are much lower. The NHS cannot afford for every person with piles to have a colonoscopy and even if it could there would be iatrogenic harm from that. There could be a bowel perforation at the worst case not to mention the worry, unpleasantness and time off work.

Doing lots of unnecessary tests on people at low risk is not necessarily the best and safest thing to do either.