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.
Q One of our patients is currently abroad and doesn’t expect to be home for two months. She has asked our GP for a short-term prescription for a stomach complaint. Are we allowed to issue this?
A It is important to understand the risks associated with responding to requests for prescriptions or medical advice from patients who are outside the UK. For patients requesting an acute prescription, you should be aware that, along with the risks associated with not being able to examine them in order to make a proper diagnosis, there are increased risks associated with treating patients in other countries. MDDUS is a UK-wide indemnity organisation and provides assistance to members for actions raised against them only within the UK and does not provide indemnity for medical treatment where the patient is located outside the UK. Members would be unlikely to be represented if action was taken against them in another country where harm had arisen as a result of their provision of medical advice. We would strongly advise members not to consult with a patient who is overseas. The patient should instead be encouraged to see a local medical practitioner.
Q One of our patients had been behaving aggressively. He made abusive comments and threats to members of the practice team on several occasions and, when he repeated this behaviour despite receiving a warning letter from us, we decided to remove him from the practice list. Now he is threatening to come back and cause more trouble, which has alarmed our employees. How can we deal with this behaviour?
A If the patient has been threatening and aggressive in the surgery then your team would be within their rights to call the police. If appropriate, speak to the patient first and emphasise that he should stay away from the practice or you will be forced to involve the authorities. You have a duty of care to your staff and to other patients and such aggressive behaviour cannot continue. It may be advisable to review the practice policy on dealing with violence/health and safety and to consult your CCG/health board’s guidelines. Consider, for example, whether staff are trained in how to deal with aggressive patients. Are there staff members working alone late in the evening? Would your practice benefit from a door buzzer entry system? Do team members have access to panic alarms? There may be some simple preventive measures that can be put in place.
Q We need to send out a message to all patients to keep them updated about changes to opening hours and the limited face-to-face services that are available during the pandemic. Are we allowed to do this or do patients need to opt in first?
A Service update messages – such as “the practice will be open for a health clinic next Monday” – would be allowed under the General Data Protection Regulation (GDPR). The intention is to inform patients about important service changes to prevent inconvenience and maintain the smooth operation of the service. Such texts are especially useful and important in the current COVID-19 pandemic. Specific patient consent is not required but the Information Commissioner’s Office (ICO) advises that a descriptor of such types of communication should be included in your privacy notice. Do not be tempted to text patients without their consent to promote a service (whether for profit or not). This constitutes direct marketing and would require explicit opt-in. Just because a patient has provided their mobile number does not mean the practice has open-ended consent to send messages.
Annual leave in lockdown
Q What are the rules on staff taking annual leave during the coronavirus outbreak?
A Rules relating to carry forward of annual leave have been extended in response to the coronavirus outbreak. The statutory four weeks provided for under the EU Working Time Directive can be carried forward and taken in the two leave years immediately following the year in respect of which it was due where it was “not reasonably practicable” to have taken it as a result of the effects of coronavirus. The latest government guidance now confirms that employees are able to take annual leave during a period of furlough. If an employee is on a period of annual leave, they should be paid their normal full-time pay for this time, with the practice able to claim back 80 per cent. You may wish employees to take any pre-booked annual leave to prevent large amounts of annual leave being taken in the latter part of the holiday year. Employers are also able to require employees to take a period of holiday by giving them double the difference in notice: so 10 days’ notice is required for a five-day holiday period. ACAS has issued some helpful guidance around annual leave which is available on their website: www.acas.org.
Online access to records
Q Our practice has an online service for patients to book appointments, order repeat prescriptions and access medical records. To apply, patients must fill out an application and present it at the surgery along with photographic ID. A mother recently filled in an application for her son, who is 14 years old, presenting his UK passport and a signed form. The email address supplied is the same as that of his mother. Is it appropriate to allow her access to her son’s personal medical records, potentially without his consent?
A Given that the son is over the age of 14, he is likely to have capacity to decide who can access his medical records. The practice should assess the son to ensure he fully understands his right to set up his own login and password to the online system. If he is considered to have capacity, he should be asked to confirm whether he is happy for his mother to have access to his records. If he is considered not to have capacity, the practice may allow access to a parent with parental rights and responsibilities. The practice should carefully consider how best to communicate with the patient and his mother. Any communication or discussion should set out the importance of consent and confidentiality and the need to ensure that all patients, taking into consideration their age, are aware of their rights.
Q I have been treating a patient who I feel has started making flirtatious comments. In our last consultation she suggested “meeting for coffee” and asked to connect on Facebook. I’ve tried to gently emphasise that our relationship is a professional one but the comments have continued. What should I do?
A This is a sensitive situation and your first port of call should be the General Medical Council’s guidance Maintaining a professional boundary between you and your patient. It is clear that you must not use your professional position to pursue a sexual or improper relationship with a patient or someone close to them. It may be worth having another discussion with the patient and politely, but firmly, explaining that your relationship must remain strictly professional. It would not be appropriate for you to meet for a coffee and it would not be advisable to connect via your personal social media accounts. If you feel unable to re-establish a professional boundary, then you may need to refer the patient to another GP. In extreme circumstances, you may need to follow the GMC’s guidance in Ending your professional relationship with a patient.
Q Our practice received a police request regarding a patient, Mr A, who was recently assaulted. The officer has asked for a statement outlining the injuries Mr A sustained and the subsequent treatment that was required. Am I allowed to disclose the information?
A The key issue here is consent. In order to disclose any information to police, you would need confirmation of appropriate consent from Mr A. Ask the detective if he has a signed medical consent form from Mr A. Alternatively, you could contact the patient and confirm whether he consents to disclosure of this medical information to the police. If you have consent, be sure to only speak to clinical records which you have access to. Avoid any discussion regarding, for example, the cause of the injuries or Mr A’s state of mind, other than that noted in the records (for example, what the patient told the practice). It may also be advisable to avoid being drawn into discussions regarding the prognoses of any diagnoses, unless this is within your competence and is appropriate in your role as a treating clinician (rather than an independent expert).
Q Our practice is currently closed to most face-to-face consultations due to coronavirus. While checking the practice inbox, I noticed an email from an elderly patient who attached an image of a rash on his leg that is causing him discomfort. The GP did not request this image (which is of poor quality) and now I am unsure what to do with it and how to abide by data protection laws.
A MDDUS has seen a sharp rise in queries of this nature. While digital photos can be helpful, particularly when patients cannot easily attend the surgery in person, they must be of sufficient quality and ideally provided following discussion with a clinician. It would be best to contact the patient to arrange for a GP telephone consultation in the first instance to discuss his concerns. If the quality is such that it has no clinical use or relevance, you should also delete the photo (and inform the patient of this step). Had the image been of sufficient quality to be clinically relevant, it could have been saved to the patient’s medical record (and then deleted from the relevant device), being sure to comply with General Medical Council guidance Making and using visual and audio recordings of patients. If, after telephone consultation, it is considered that a better quality photo would be of clinical use, this can be discussed with the patient and submitted via appropriate portals (in line with current practice, given the limited access to face-to-face consultations). If direct clinical examination is felt to be necessary, then the patient should be asked to attend the practice. It may also be worthwhile reviewing the practice’s notices and policies regarding use of the practice email address.