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 A 52-year-old patient has been a frequent attender at the practice for the past eight months. At her last appointment, she insisted on giving bottles of whisky as Christmas gifts for the two GPs who have been caring for her. Each bottle is worth around £50. The patient said she simply wanted to show her appreciation after such a tough year. Can the GPs accept these gifts?
The General Medical Council states in Good medical practice that a doctor “must not ask for or accept – from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients”. The regulator also provides supplementary guidance in regard to financial and commercial arrangements and potential conflicts of interest. This states that a doctor may accept unsolicited gifts from patients or relatives but should consider whether by doing so they are altering their relationship with the patient, and also how this may be perceived by the public in general. Doctors should therefore proceed cautiously when considering accepting a gift. The practice should be satisfied that all actions taken are in accordance with such guidance and must be prepared to explain and justify any decisions made and actions taken. The acceptance of gifts by general practitioners is also subject to statutory and contractual regulations. The General Medical Services Contract Regulations highlight that a register should be kept of gifts received of a value in excess of £100, unless the gift is unconnected with their professional services. This register should include details of the donor and the nature of the gift, including whether it was given to the practice or an individual.
Q One of our GPs was asked by a business to prepare a medical report for a patient who works for them. The patient consented on the condition that she be allowed to read over the report before it is sent. We informed the patient that the report was ready for review two weeks ago but she has not been in touch. Can we assume she does not wish to review it and send the report to her employer?
Under the Access to Medical Reports Act 1988, patients (in England, Wales and Scotland) have the right to access an employee medical report before it is sent to their employer. To do so, the patient should make contact with their GP within 21 days of the report being requested. In this instance, it would be advisable to wait for the full 21 days to pass before sending to the employer. You could also consider phoning the patient as a courtesy to remind her the report is ready for review and will be sent to her employer after 21 days. If she does review the report, she has the right to ask for amendments to any part she considers inaccurate or misleading. If the GP declines to make the changes, a written statement should be attached to the report setting out the patient’s views. The patient also has the right at that point to withhold her consent to the report being released to her employer.
Aggressive patient disclosure
Q Our practice recently decided to remove a patient from our list for continued aggressive behaviour. We had followed all the necessary steps, including discussing the matter with him on several occasions and writing to advise him that if his behaviour continued we may be forced to remove him. He has since instructed a solicitor to contact the practice, objecting to his removal and asking for the names of the people who accused him of behaving aggressively. Are we obliged to disclose that information?
In a situation like this, you would not be obliged to disclose information that is privately held by the practice. You could provide a clear explanation as to why the patient was removed to help him understand the reasons behind the practice’s decision. Any information should have third-party details redacted. But if he wants to know the names of those who raised concerns about his behaviour, the patient would need to ask his solicitors to seek a court order (which is unlikely in a case like this). The practice has a duty to protect patients and staff and in some instances this means taking the difficult decision to remove a patient from their list. An MDDUS adviser offers to assist the practice in drafting a suitable response to the solicitors.
Q One of our nurses has found out that she is pregnant and is worried about working in the practice during the pandemic. She does not have any underlying medical conditions, but has asked if she can work from home. Because of the nature of her role, this is not possible. Are we obliged to keep paying her if she stays at home?
The UK Government classes pregnant women as clinically vulnerable and it is recommended that they should work from home where possible. Although there is no evidence that pregnant employees are more likely to get coronavirus, they should be especially diligent about social distancing. Under the Management of Health and Safety at Work Regulations, all pregnant employees must be subject to a risk assessment to discuss and eliminate any risk. Where a risk is identified, the employer must take steps to control, reduce or remove it. If the practice is unable to do so, the employee needs to be placed on full pay suspension. It is for the employer to discuss the situation with the employee and establish what her specific concerns are. This should include the role she carries out, the safety measures that the practice has put in place and any personal protective equipment (PPE) she may be required to wear as part of her role. Any logistical issues should also be considered, such as how the employee travels into work and if public transport has to be used.
If the specific concerns about working in the practice cannot be resolved, then the practice may wish to consider whether there is any other practice work that the nurse could do from home. Women who are less than 28 weeks pregnant may choose to continue to work in patient-facing roles as long as a risk assessment has been carried out and the necessary precautions have been taken. For women who are more than 28 weeks pregnant, and/or who have underlying health conditions, direct patient-facing contact should be avoided. Guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) advises that pregnant employees should not see patients face-to-face after 28 weeks. If no other work can be found or the employee is unable to work from home, then they should be placed on paid leave.
Q Our practice nurse has a young son whose school has had to close following an outbreak of coronavirus. She has asked if she can stay at home to look after him. Is she entitled to any kind of paid leave?
Employees are entitled to unpaid time off work to help someone who depends on them in an unexpected event or emergency (Emergency Time Off For Dependants Leave). This would apply to situations relating to coronavirus, such as a school closure. But there may be emergency childcare available for key workers (assuming the child has not been directed to self isolate). In the first instance, ask your team member to speak to her son’s school or to the local authority to see if such an arrangement is available.
If she still requests time off for childcare despite the availability of emergency arrangements, there is no statutory right to pay for this time off. You may offer to pay her depending on the employee contract/practice policy, or you could suggest she takes annual leave. The amount of time off an employee takes to look after someone must be reasonable for the situation.
Q One of the practice receptionists says he has been approved to act as an emergency statutory volunteer and has requested two weeks’ leave. How does this scheme work?
The Coronavirus Act 2020 introduces a new statutory right for workers to take emergency volunteering leave to help support essential health and social care services. Employees and workers who have been certified by an appropriate authority to act as an emergency volunteer will be able to take unpaid leave in blocks of two, three or four weeks. To take the leave workers must:
- give three working days' notice
- produce a certificate from the appropriate authority confirming they have been approved and will be acting as an emergency volunteer for the period specified in the certificate.
A UK-wide compensation scheme is to be set up to compensate volunteers for loss of earnings, travel and subsistence. Workers will remain bound by terms and conditions of employment (except those relating to pay) and there will be a statutory right to return to their job. Employers are not able to refuse unpaid leave to an employee who wishes to carry out volunteer work unless they have less than 10 staff. There is, however, nothing to prevent an employer with a headcount of less than 10 staff agreeing to such a request and it is worth bearing in mind that furloughed employees can take part in volunteer work.
Serious case review
Q We have been informed that a serious case review is to be held following the death of an 88-year-old patient. One of our trainee GPs saw the patient a few times in the months before he died and has been asked to give a statement. What should she write?
The General Medical Council's Good medical practice states that, to help keep patients safe, you must contribute to confidential inquiries and adverse event recognition. All doctors have a professional duty of candour and the GMC’s supplementary guidance on this topic provides further advice on ‘encouraging a learning culture by reporting errors’. Good medical practice paragraph 71 states that doctors must make sure that any documents they write or sign are not false or misleading. They must also not deliberately leave out relevant information. The doctor should keep the statement factual and beware of straying into opinion, and avoid criticism of colleagues. The doctor can submit their draft statement for review by an MDDUS adviser before submission.
Q A patient has phoned the practice asking to be prescribed antibiotics for a dental problem. We advised her to speak to her dentist but she said that she could not afford the £75 fee that would incur. Are we obliged to help her even though it’s a dental problem?
A scenario like this is surprisingly common and practices would be advised not to automatically turn away patients with dental complaints. It is true that GPs are not contractually obliged to administer dental care and are also legally restricted from doing so (under the Dentists Act 1984) unless they are dually qualified. However, they do have an ethical responsibility to offer help in an emergency. This can extend to medical care where the patient requires urgent treatment for pain or an infection.
Before issuing any prescription, it is vital to assess the patient to exclude other non-dental conditions. Only if you are satisfied the issue is solely dental should you signpost to a dentist, local emergency service or, for serious cases, secondary care. Doctors should also be alert to signs of spreading infection or systemic involvement of a dental infection as this would require an immediate secondary care referral. Be mindful of the General Medical Council's Good medical practice guidance which clearly states you must recognise and work within the limits of your competence. Don't be pressured into giving the patient a medication or treatment if you’re not sure it is in their best interests. Read more detailed advice on dealing with dental emergencies here.