These cases are based on actual calls made to MDDUS advisers and are published here to highlight common challenges within general practice. Details have been changed to maintain confidentiality.
Q Our practice has been contacted by Ms G, the sister of our patient Mr B. Mr B has learning difficulties and other health issues and Ms G is worried he is not looking after himself properly. Ms G – who lives abroad – wants the practice to “do something” to help her brother and says it would be “on our heads” if he came to any harm. Ms G hasn’t told her brother about her request to the practice and Mr B has a history of not engaging with care services. What should we do?
A The key consideration here would be whether Mr B has the capacity to make decisions about his own care. If his GP believes he is competent, then Ms G must understand that her brother cannot be forced to engage with care services if he chooses not to. The practice could consider contacting Mr B to discuss his sister’s concerns by phone, in writing or face-to-face if appropriate. If Mr B chooses not to respond then the practice should consider how long to persist in their attempts to reach him. The practice could also suggest Ms G contacts social services for more detailed advice about her brother’s situation. A note should be made in Mr B’s record of the concerns raised by Ms G and any subsequent attempts to contact him.
Consent to immunise
Q One of our patients is due to bring in her baby for his vaccinations but the father has been in touch to say he does not want his son to receive the jabs because he is not convinced they are necessary or safe. The mother is adamant the child must be immunised. Can the practice go ahead with one parent’s consent?
A The practice cannot deliver a vaccination to a young child in the knowledge that the father is withholding consent (assuming the father has parental rights and responsibilities). The exception would be if there is specific court approval that the immunisation is in the best interests of the child. Discuss the issue with the father and try to understand his reasons for refusal. Explain the importance of childhood vaccination and reassure him over their safety. Encourage him to reach agreement with the boy’s mother in the best interests of his son. If appropriate, refer the father to external information sources, for example The Vaccine Knowledge Project at Oxford University. UK healthcare professionals can find more guidance on vaccinations in The Green Book.
Q I am a GP and would like to take some time out to work abroad for a few months with Medecins Sans Frontieres (MSF). Would MDDUS provide me with indemnity in the event that any kind of complaint or claim is made against me while I’m abroad?
A MDDUS assists members undertaking their professional roles in Scotland, England, Wales, Northern Ireland, the Channel Islands and the Isle of Man. We would be unable to offer benefits outside of these jurisdictions, other than in respect of Good Samaritan Acts. Members can find details of their specific indemnity in the Member Guide and as stated in their individual membership information sheet which would have been sent with their membership pack. If you do choose to work abroad, you would need to ensure you have the appropriate indemnity in place for this. It may be helpful to speak to MSF to find out whether they can provide appropriate indemnity for the work you plan to undertake.
24 hour phone line
Q We currently provide a 24-hour repeat prescribing line which has proved very popular amongst the practice patients. We are reviewing the way the line is operated and have concerns over potential safety risks. What’s the latest advice around this type of service?
A For a service such as this, it may be useful to carefully consider how the phone line is operated, step by step. Who answers the phone and takes the patient’s request? Who issues the repeat prescription, how is it generated and who signs it? Familiarise yourself with the General Medical Council’s guidance Good practice in prescribing and managing medicines and devices, particularly paragraphs 98 to 102 which refer to repeat prescribing. The GMC is clear that doctors “are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats and, where possible, reduce repeat prescribing.” It adds that doctors “must be satisfied that procedures for prescribing with repeats and for generating repeat prescriptions are secure”. Your local health board/CCG may also have some practical advice for operating a service like this.
Patient on holiday
Q The practice has received a call from someone (a UK resident) who is visiting the local area on holiday and needs advice for what appears to be a minor ailment. Are we able to help her or should we refer her back to her own GP?
A As travel restrictions ease, it is likely that practices will see an increase in enquiries like this. In this case, the NHS advice is for the patient to contact her own GP for assistance in the first instance. If a prescription is needed, this can be sent via Electronic Prescription Service (EPS). Practices may also make use of the Community Pharmacist Consultation Service which is set up to refer patients requiring “low acuity advice, treatment and urgent repeat prescriptions” to community pharmacies. Ensure the practice’s triage system is up to date and working effectively to ensure that anyone seeking medical help is appropriately advised and signposted. It is also worth bearing in mind the General Medical Council’s guidance in Good medical practice which states that “you must give priority to patients on the basis of their clinical need, if these decisions are within your power.” NHS England have also published a useful guide for patients who need to see a GP away from home.
Q Over the past year, quite a few of our patients have failed to attend (DNA) secondary care referral appointments made by GPs at our practice. Would the practice be held responsible for any harm/deterioration in condition that the patient may suffer as a result of a DNA?
A The General Medical Council’s guidance Delegation and referral states that a doctor is not accountable for the actions (or omissions) of those to whom they delegate care or make referrals, However, a doctor will be accountable for their own decisions to transfer care and the steps taken to make sure that patient safety is not compromised. The practice may wish to consider the possible reasons for patient non-attendance at secondary care appointments. For example, did the patient receive an appointment letter? The referring doctor would likely bear responsibility for ensuring the correct patient contact details were provided on the referral form. Also, depending on the seriousness of the case, the GP may feel it is appropriate to contact the patient and invite them for a review at the surgery. When making a referral, it is helpful to make sure the patient understands why the referral is being made and the implications of non-attendance. They should also be supplied with appropriate safety-netting advice. It is worth noting that a patient who has capacity and is fully informed has the right to choose not to attend clinical appointments.
Q A 24-year-old patient, Ms A, attended the practice to request a test for sexually transmitted illnesses (STIs). She told the nurse the reason for this was that she had been sexually assaulted a few weeks previously. The nurse encouraged her to report the incident to police and offered her support but she declined (she has capacity). Is there anything else we should do?
A As you are aware, a patient with capacity has the right to refuse treatment or interventions. As long as you are satisfied Ms A is not vulnerable or at risk from further abuse then it would be her decision as to whether or not she reports the incident to police. The nurse has acted properly in reassuring Ms A that the practice would support her in whatever way they can going forward. It is important that the practice take this commitment seriously and ensure the patient’s health needs are met. This may include full STI screening, investigation of any other reported symptoms and perhaps also mental health support. You should ensure that all documentation is factual and accurate in Ms A’s medical records and emphasise that these will remain confidential at the practice.
Q A medical student has been in touch with the practice volunteering to help the team cope with the extra pressures of working during the pandemic. Would we be allowed to accept her offer?
A Medical students may be able to offer a source of assistance to the healthcare team. Students would be offering voluntary help and should not be carrying out any duties of a doctor. If you do wish to accept the student’s offer, she should only be asked to undertake tasks she is competent to perform and satisfactory supervision should be in place. You may suggest she takes a look at the GMC’s coronavirus guidance for students, or guidance for students from the Scottish Government. NHS Resolution have clarified that volunteers asked to assist delivering NHS services, who have a volunteer agreement in place, will have indemnity for clinical negligence through the Trust’s indemnity scheme. They have stated that similar arrangements are in place across other devolved UK nations.