Case Study 5

Question 1

Michelle is a 55 year old office worked with COPD and bronchiectasis. She has been stable for a number of years but has been unwell with recurrent chest infections over the last three months. Several different antibiotics have failed to help despite sputum culture and appropriate antibiotic sensitivities being noted. She has poor appetite, has lost weight and her mood is low. Following discussions, you decide to refer her back to the chest clinic, employing your role as “gatekeeper”.
What is meant by the term “gatekeeper”? (in medical context)

Answer 1

The person who controls patients’ access to specialist or secondary care

Question 2

List four advantages of GPs as gatekeepers

Answer 2

• identify patients in need of secondary care assessment
• personal advocacy
• patient does not necessarily know which specialty to go to
• increases likelihood of referral to appropriate department
• increases likelihood of appropriate referral/use of resources
• limits exposure to certain investigations e.g. MRI, Xrays
• GP acts as co-ordinator of care
• puts GP in a position to provide patient education

Question 3

Approximately what percentage of illnesses occurring in the community are referred onto secondary care?

Answer 3

3%

Question 4

List three health and social care members who work within the community who a GP may decide to contact to assist with a patients care, and give an example of their role

Answer 4

• Physiotherapist e.g. to help clear chest secretions
• Pharmacist e.g. advice on medication/interaction/timing of antibiotics/encouragement re concordance
• Dietician - assessment on nutrition and advice on improving appetite/weight gain
  Counsellor - assessment and management of low mood
• Practice nurse - assessment and advice re inhaler use/chronic disease monitoring clinics/flu and pneumococcal immunisation
• Occupation therapist - assess for aids to assist daily living e.g. stair lift, shower rail

Question 5

You decide Michelle’s recent care has been sufficiently complex and challenging to warrant writing up a Significant Event Analysis. As you do this you reflect on the four ethical principles that underpin medical practice. One of these is justice. Give the other three.

Answer 5

• Beneficence (do good)
• Non-Maleficence (do no harm)
• Autonomy

Question 6

Michelle feels her inhalers are not as effective as they used to be and her concordance with treatment is erratic.
Explain how each of these ethical principles may apply to Michelle’s scenario

Answer 6

• Beneficence - her care has been maximised i.e. treatment of infection, discussion with colleagues in microbiology, involvement of practice team, referral for specialist opinion
• Non-Maleficence - culture of sputum and discussion with microbiology to minimise risk of antibiotic resistance
• Autonomy - patients right not to take advised treatment (inhalers) even if full informed of benefits