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.
Advance care planning during the pandemic
Q Our practice list has a large elderly population, with many in care homes. Can we carry out advance planning for groups of patients (for example DNACPR orders)?
A The COVID-19 pandemic presents unparalleled challenges to healthcare providers and it is natural that processes to improve efficiency are being considered. However, person-centred care is at the heart of clinical practice and any discussions about plans for future care (including DNACPR orders) must be individualised to that patient. Even during a pandemic, where resource pressures are being felt acutely, it is not acceptable to apply future care plans to groups of patients, even if patient cohorts have similarities. When considering advanced or anticipatory care planning for a patient, doctors must ensure they take into account the relevant legal frameworks (such as capacity legislation), as well as their professional and ethical obligations. Discussions about a patient’s future wishes are emotive and should be approached sensitively. A patient must be aware of their options and given the opportunity to consider their wishes. Those close to the patient and others in the healthcare team should also be involved, as appropriate. The GMC/NMC have published a helpful statement setting out the appropriate guidance and considerations in such matters.
Samaritan on the doorstep
Q Our practice is on a busy shopping street next to a major supermarket and pharmacy. Over the years we have had numerous occasions where our GPs were expected to provide assistance to pedestrians needing “urgent” medical care? Are they obliged to do so and would they be expected to leave their patients waiting?
A Doctors in the UK have no legal obligation to assist in an emergency outside the terms of their contractual duties, but there is an ethical obligation. In Good Medical Practice the General Medical Council advises that doctors “must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care”. In the case of someone needing urgent medical care it would be likely that the practice has been sought out knowing that a medically trained person would be on site. This scenario would be a little different from a passing-by, off-duty doctor assisting a stranger in need (as a Good Samaritan). Nevertheless, the doctor would need to make a decision at the time as to which party would most require their attention – the patient in the waiting area or, for example, a shopper who has collapsed in the nearby supermarket. In acting as a Good Samaritan, doctors must abide by the same ethical duties that apply in conventional patient care and ensure that the patient is their first concern. Doctors are also obliged to act within the scope of their competence to make clear any limitations to those in need and those attending – this includes the issue of consent or best interests in a patient who may lack capacity. It is essential to work collaboratively with any other medical professionals who attend a person in need, gauging who is best to assist and lead the care. MDDUS provides GP members with access to indemnity, support, advice and representation for claims arising from worldwide Good Samaritan acts.
Q What is our legal obligation in regard to compassionate leave for staff? A nurse practitioner in our practice has been off work for four weeks having suffered a bereavement.
A There is no statutory compassionate leave entitlement under current UK law. However, the Employment Act 1996 does specify that employees can take time off with the death of a dependant. Acas advises that anyone classed as an employee has the right to time off if a dependant has died, including a partner, parent or someone else who relied on them. An employee having lost a child under the age of 18 or a stillborn baby after 24 weeks of pregnancy has the right (since April 2020) to two weeks paid parental bereavement leave. Otherwise there is no legal obligation for bereavement leave to be paid, although some employers do so. You should check the contract of employment and your workplace policy. The law also does not stipulate how much time can be taken off if a dependant dies but simply says the amount should be “reasonable”. Read more from Acas.
HCA providing cryotherapy
Q Our practice would like to train a healthcare assistant (HCA) to provide cryotherapy for warts and other simple lesions that have been diagnosed by a GP. Is an HCA allowed to undertake this kind of treatment and would MDDUS provide indemnity?
A There is no specific list of tasks that a HCA can perform but we advise that you follow General Medical Council guidance on delegation: ‘‘When delegating care you must be satisfied that the person to whom you delegate has the knowledge, skills and experience to provide the relevant care or treatment; or that the person will be adequately supervised. When you delegate care you are still responsible for the overall management of the patient." An HCA will be covered by vicarious liability under an MDDUS practice group scheme as long as they are carrying out tasks that have been appropriately delegated. Any incident or concern raised will be the responsibility of the GP who delegated the care and that GP will be accountable to the GMC if the care of that patient is criticised. The practice should document the training and supervision provided to the HCA, including in-house training and/or external courses. It remains the responsibility of the GP to diagnose and allocate appropriate patients to the HCA for treatment and it might be prudent for the delegating clinician to be responsible for obtaining informed consent and ensuring that this is appropriately documented.
Face covering required
Q We require patients to wear face coverings in our practice. What can we do if a patient refuses?
A This is a difficult situation. First it is important to explore why the patient is refusing to comply and if there is any valid reason, perhaps including a medical reason. Some patients may not fully appreciate why a face mask is required. Should the patient persist in refusing, consult latest guidance from the NHS and governmental departments of health and undertake a risk assessment to judge what would be reasonable in the circumstances. Remember that you have a professional obligation to make the care of the patient your first concern. A decision to deny care in such circumstances would need to be sufficiently justified. GMC guidance states: “If a patient poses a risk to your health or safety, you should take all available steps to minimise the risk before providing treatment or making other suitable alternative arrangements for providing treatment”. Consider the following factors in assessing the risk:
- Does the clinician have adequate PPE?
- Does the patient have symptoms or a confirmed COVID-19 infection?
- Is the clinician known to be at higher risk?
- What is the duration of contact and can the patient maintain sufficient distance?
Be aware that you could be criticised for any global policy to deny care to patients refusing to wear face coverings. Practice policies should build in flexibility to consider the particular circumstances of individual patients.
An anonymous letter
QOur practice manager has received an anonymous letter alleging that one of our patients is faking illness for the purposes of prescription fraud. How should we handle the situation?
A Such communications should be treated as hearsay and dealt with using great caution in the first instance. You may wish to bring the letter to the attention of relevant staff so that it can be considered when the patient next attends. However, the practice should not treat the concerns raised as a matter of fact. Consider discussing the letter with the patient to obtain his or her response but be careful not to discriminate against the patient in any way on the basis of the letter, as it may be vexatious. Note that such letters should not be stored in the patient’s medical records.
Flexible working request
Q We have a receptionist returning to work from maternity leave. She has hinted that her current hours will not be suitable on her return to work, given her childcare needs. We are a small practice with only three administrative staff. Are we obligated to change her working hours?
A The employee has the right to return only to the hours that she left but she can submit a flexible working request. Flexible working regulations allow employees to request a more flexible working pattern but in a manner compatible with business efficiency. A flexible working application may cover such aspects as hours of work and times or place of work, and employees can request a range of different working arrangements, including part-time working, flexi time, job-sharing and working from home. To be eligible to apply, an employee must have worked for the practice for at least 26 weeks and not made a previous application in the last 12 months. A meeting to discuss the request should be arranged and the employee has the right to be accompanied by a work colleague. In assessing a flexible working request, you should consider the benefits both to the employee and the practice and weigh these against possible adverse impacts. An employer can refuse a request for flexible working for a number of reasons, including the burden of additional costs, any detrimental effect on the ability to meet patient demands, an inability to reorganise work amongst staff or recruit additional staff, and possible compromised practice quality and performance. All requests, including any appeals, must be considered and decided on within a period of three months from first receipt of the request but this period can be extended in agreement with the employee. Ensure that all such requests are dealt with fairly and consistently, but the practice is not obliged to alter working hours.
Opt out for screening
Q Recently a patient informed our practice nurse that she has opted out of her local cervical call/recall system and no longer wishes to be contacted in regard to cervical screening. We are unsure of our legal obligation. Should we request that the patient sign a disclaimer or does responsibility rest with the local screening service?
A Provided the patient has the capacity to understand the implications of opting out of the cervical screening programme and is fully informed, she has the right to do so. However, it would be her GP’s responsibility to ensure she has received sufficient information to make an informed choice. She should also be advised that she can change her mind at any point and can be re-enrolled in the screening programme. The use of a disclaimer is not appropriate in this case, as there is no substitute for detailed documentation about the patient’s choice, the discussion about the decision to be made and the clinician’s assessment of the patient’s ability to make that decision. The practice must ensure that the cervical screening programme has the information it needs in order to comply with the patient’s request.
Request for medication details
Q A GP in our practice has received a request from a consultant psychiatrist wanting a medications history for one of our patients. Should we seek the patient’s consent before forwarding the records?
A The GMC provides detailed guidance to doctors in relation to issues surrounding Confidentiality. You will note from this guidance that the GMC recommends that doctors obtain the patient’s consent before they disclose medical information to any third party. However, a member of the medical team involved in a patient’s care is not considered to be a third party and therefore it is reasonable to provide them with relevant information, as there is an assumption of implied consent from the patient. In this case, if the patient has not specifically highlighted that they do not wish specific information to be disclosed to their treating consultant psychiatrist, then it should be appropriate for the GP involved to provide relevant information to assist treatment.