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    The NHS has undermined its own advice on sepsis

    28 February 2018

    As we come to the end of the annual NHS winter crisis, I can only imagine that parents of young children are feeling increasingly confused. NHS England has recently advised them to take their unwell children to a chemist rather than their overstretched GP. Yet at the same time there’s a campaign to raise awareness of sepsis, and the importance of early intervention. As a hospital doctor with substantial experience in A&E, I’m baffled.

    Several years ago few people would have heard of sepsis, a potentially life-threatening condition produced by the body’s overwhelming response to an infection. Fewer still would have had a decent grasp of its sometimes insidious signs and symptoms, cryptic clues which must be acted upon before the body unleashes an onslaught of dysfunctional physiology.

    Partly due to the ubiquity of social media, campaigns for heart attack and stroke recognition have been dwarfed by the impact of last year’s drive for greater sepsis awareness. The worried parent’s question is no longer ‘could it be meningitis?’, but often ‘is it sepsis?’. This line of questioning to doctors and nurses should be welcomed; while such awareness may cause undue worry, the renewed emphasis on sepsis can focus both the tired minds of doctors as well as parents and potentially save lives.

    Jeremy Hunt has been a champion for this cause, and while sincerity may not have always been a bedrock of his tenure as Health Minister, he seems genuine in his desire to avoid misrecognition of critically unwell patients.

    In March 2017 Jeremy Hunt attended the memorial service for a boy named William Mead, a one year old who tragically died of sepsis in 2014 following an alleged series of missed opportunities to recognise his condition. Hunt apologised at the service, saying ‘we didn’t spot his sepsis before it was too late’. His apology was appropriate, and probably even heartfelt. However nine months later, NHS England – the organisation he directly oversees, now recommend that children with ‘minor illnesses’ should be seen at their local pharmacy.

    The whole premise upon which this advice is based may not, on the face of it, seem so perverse, as it is clear that a significant proportion of A&E attendances are not real emergencies. However the misdiagnosis or under-treatment of a child developing sepsis is more often than not due to the very belief they have only a ‘minor illness’. Awareness campaigns are designed to effectively challenge, no matter how briefly, the belief of a relative, parent or doctor that an individual has only a trivial ailment. Thus to suggest a worried parent should make the diagnosis of minor illness themselves and take the child to a chemist seems to miss the point.

    I absolutely wish to cast no aspersion on my pharmacist colleagues; they are a veritable wealth of knowledge on medications and interactions between different drugs, and I am quite sure in most cases can differentiate a very sick child from one with a cold. But most cases is not enough, and to place this burden upon those not fully medically qualified, who would not perform the basics, such as listening to chests and looking in throats, is an unrealistic expectation.

    While there have of course been instances of GPs and hospital doctors missing cases of meningitis or septicaemia, consultations are private and thorough, and we are well-trained in the crucial provision of ‘safety netting’ – the things for mum and dad to watch out for which might suggest something worse than we initially thought. If I were to tell a chemist that during a general practitioner’s career, they will typically encounter and need to identify two children with meningitis amongst a vast ocean of kids with temperatures and snotty noses, I suspect they would be keen to shrug off this latest ruse.

    Nor should we assume that such a move, regardless of risk, will necessarily have the desired effect of shortening the three or four hour wait currently endured at our local A&E.

    Chemists have managed such ailments as coughs and colds with conventional remedies for time immemorial. But by virtue of this expanded role being mooted, a greater unspoken onus will now be placed on chemists to triage and refer the slightly less well to a doctor. With greater responsibility comes defensiveness, and I suspect this may unwittingly lead to more GP and hospital appointments than were needed before.

    NHS England’s latest desperate attempt to reduce pressures on GP practises and A&E waiting rooms is ill-thought through, and may even be counter-productive. They are applying a flimsy dressing to a gaping wound which can only be healed by greater resources, and actually meeting increased demand with appropriately trained staff.

    Raised awareness for life-threatening conditions is essential and the government have made a show of being invested in such progressive moves; advising unwell children to be seen at a pharmacy diminishes the entire message, and should be met with the resistance it deserves.