These cases are based on actual calls made to MDDUS advisers and are published here to highlight common challenges within practice management. Details have been changed to maintain confidentiality.
Consulting via social media
Q I have a patient being treated for a chronic condition and we recently discussed switching medication and agreed to do some baseline bloods first before changing the prescription. The patient has now sent me a friend request via LinkedIn with a link to an article assessing a possible alternative medication. Is it okay for me to reply to this message with a link to another article showing there is no conclusive evidence supporting increased efficacy in the suggested drug? LinkedIn is a “professional” platform and the question is treatment-related.
A It’s best to be cautious about this type of communication with patients. GMC guidance on Doctors’ use of social media highlights that boundaries can become blurred when communicating through sites such as LinkedIn. It states: “If a patient contacts you about their care or other professional matters through your private profile, you should indicate that you cannot mix social and professional relationships and, where appropriate, direct them to your professional profile”. The guidance also states: “social media sites cannot guarantee confidentiality whatever privacy settings are in place”. We would advise that you inform the patient that you do not use LinkedIn or any other social media platform for clinical communication and provide a range of options to contact you via the practice.
Access to teen's records
Q A 13-year-old patient at our practice has fallen out with his mother and is now living with his father. The mother has recently been in touch with the practice in regard to an ongoing health issue with the boy – but he no longer wants her to have access to his healthcare information. What is our legal position?
A Given the age of the boy it is possible he would be judged Gillick competent with capacity to refuse disclosure of his personal medical information. We advise that the practice writes to the mother stating that, in order to consider whether information can be disclosed to her, the boy would need to be assessed by a GP regarding whether he is competent to make this decision for himself. It may be the mother would not want her child to be informed of her request. If she is content for this assessment to be undertaken and he has capacity but refuses, this would ordinarily be definitive. If he does not have capacity and the mother maintains parental responsibility, the key issue is what is in the child’s best interests to disclose.
Keeping insurance records
Q How long is our practice required to retain copies of completed medical insurance reports?
A Insurance forms are covered by the Access to Medical Reports Act 1988 and this allows for patients to request to see a report or have a copy of a report up to six months from the date of it being written – thus the practice would be expected to keep copies of these documents for a minimum period of six months. Principle 5 of the Data Protection Act 2018 is also relevant here, stating that personal data processed for any purpose shall not be kept for longer than is necessary for that purpose. Compliance with this legislation would suggest a practice policy of safely disposing of insurance forms after six months. MDDUS advises filing such reports independently of medical records so they can be easily reviewed and kept for no longer than is necessary in compliance with Data Principle 5.
Q An elderly patient recently attended the practice for an appointment having come from the pub. He was clearly inebriated, smelling of alcohol, stumbling and slurring his words. The GP refused to see the patient and asked reception to make another appointment for later in the week. The patient was clearly not happy and made a fuss in the waiting room. He is registered with the practice and has no history of alcohol dependence. Are we allowed to refuse to see an intoxicated patient in such circumstances?
A Conducting a consultation with an inebriated patient would clearly affect your ability to obtain a detailed history and perform an appropriate clinical examination. In such circumstances it would be appropriate to make an initial assessment of the patient to consider whether other issues are the cause of the patient’s presentation and whether it would be unsafe to allow him to leave the practice in this state. It may be advisable to discuss the matter with practice colleagues to determine whether the patient may require further assessment/treatment for potential alcohol dependency. In the event that the patient displays abusive behaviour, you may later wish to issue a formal warning that such behaviour will not be tolerated and could lead to removal from the practice list.
Q I’m a GP partner at a practice and have been asked by a friend if his daughter can shadow me for a few sessions. She is in her final year at school and is applying for medicine at university. Is this problematic?
A Work-shadowing arrangements are not uncommon but there are a number of issues to consider. First a risk assessment should be performed and recorded prior to such an attachment to ensure that the work environment is safe for a visiting pupil. The Health and Safety Executive has published guidance related to work-experience pupils . It is also crucial to consider issues of confidentiality and consent. The pupil should be required to sign an agreement and given firm guidance that personal patient details (even the fact that someone has attended the surgery) are entirely confidential. Patients must be asked for consent in advance (preferably in writing) for a school pupil to be present during a consultation and should also be advised that they may change their mind at any time. Notices in the waiting room to indicate that school pupil placements may occur are also helpful. Pupils should be informed that they cannot expect hands-on experience and will only be observing on a limited basis (e.g. no examinations). Finally, it is important that the whole practice team are comfortable with the arrangements to ensure the pupil is appropriately supported and supervised.
Q We hired a medical receptionist on a six-month probationary basis but there have been a number of issues arising in that period. These include not complying with practice protocols and procedures despite being given repeated training. She has also stated that she will not be available to cover annual/sickness absence which was clearly outlined in her interview. I have discussed these concerns and informed her that at present we will not be offering her a permanent employment contract. Are we within our rights?
A An employee with under two years’ service does not have unfair dismissal rights. As long as there are no protected characteristic issues (such as disability, sex, race, pregnancy etc), it should be straightforward to advise the employee that her probationary period has not been successful. She should be given her notice – which can be worked or paid in lieu – along with any accrued outstanding holiday pay up until the termination date. MDDUS members can request a template letter by emailing email@example.com.
cc'ing the GPQ Our practice is trying to reduce workload and one thing that crops up repeatedly is consultants copying the GPs in on bloods/histology results that they (the consultants) have requested. Can we assume that the consultant will follow-up on results if abnormal? Could the practice be held liable for failing to inform the patient of an abnormal result for a test that we did not request?
A The doctor who initiates an investigation is ultimately responsible for following it up and advising the patient accordingly (or making clear alternative arrangements) but there are often cases in which continuity and coordination of care are required. The GMC highlights that in delegating care you must ensure that you “share all relevant information with colleagues involved in your patients’ care within and outside the team”. In the circumstance described, the consultant initiating the investigation is likely to be responsible for reviewing the patient. However, as this information is being provided to a GP in the practice it should not be simply ignored – especially if urgent action is required. It would be difficult to defend adopting a specific policy not to review copied correspondence. Ultimately, if there is any confusion, it would be necessary to clarify with the originating healthcare professional what are the follow-up arrangements for the specific patient. You could also discuss this matter further with your LMC, who may have a policy on the matter or would be able to advise you if similar instances have occurred with other practices.
Q Our practice recently discussed the possibility of chaperone training for non-clinical staff. Is it a legal requirement to undertake DBS checking for prospective staff wishing to act as clinical chaperones?
A In the first instance it would be important to consider whether it is appropriate for a non-clinical staff member to act in this role. GMC guidance on Intimate examinations and chaperones states that a chaperone “should usually be a health professional and you must be satisfied that the chaperone will:
- be sensitive and respect the patient’s dignity and confidentiality
- reassure the patient if they show signs of distress or discomfort
- be familiar with the procedures involved in a routine intimate examination
- stay for the whole examination and be able to see what the doctor is doing, if practical
- be prepared to raise concerns if they are worried about the doctor’s behaviour or actions."
The guidance also states that a “relative or friend of the patient is not an impartial observer and so would not usually be a suitable chaperone, but you should comply with a reasonable request to have such a person present as well as a chaperone”. MDDUS would suggest that you review the guidance as a whole to assist in your decision-making in this matter – but should the practice still wish to consider the use of a non-clinical chaperone it is important that you are able to clearly explain and justify this decision. We would also advise that you ensure the person is appropriate and reaches the above standards. Most health professionals will have already undergone DBS checking and we would anticipate that non-clinical chaperones would also require vetting.