As a mutual organisation, we feel it is important to undertake this analysis and inform members so that they may be better equipped to manage these risks in their own practice.
Two-thirds of claims against GPs relate to the diagnosis and investigation of presenting symptoms and conditions. Only a small number of cases are related to poor clinical judgement or treatment, and instead many arise due to failures in practice systems. Here I will highlight some of the common causes – and associated lessons – underlying the large group of these claims which are related to practice systems.
Delay or failure to assess
Appointment system failures
Failures here can arise from lack of available appointments in the practice or inappropriate triage and channelling of patients requesting appointments. Many practices can be over-reliant on nonclinical staff to manage patient demand, without appropriate and safe mechanisms by which they can request advice or override protocols when concerned.
Lesson: GPs should ensure that nonclinical staff are aware of their limitations and boundaries in dealing with patients requesting appointments when there is little or no availability. The culture should be that staff can approach clinicians for advice or assistance easily via agreed mechanisms and that they should not provide clinical advice to patients as an alternative to appointments.
Not utilising the clinical notes as a communication tool for the next clinician (e.g. recording positive and negative findings on examination and recording differential diagnoses) can lead to subsequent clinicians having inadequate information about a patient’s condition.
Lesson: Clinicians should make adequate records for their colleagues/themselves in relation to history-taking, examination, differential diagnosis and treatment.
Delays or failures to organise tests
It can be notoriously difficult to ensure the robustness of practice results-handling systems. There is currently no one-size-fits-all solution to managing testing and the receipt and actioning of results. We have produced a checklist to help members review their results-handing procedures with their team (see below). However, the strength of this system will be dependent on the competence and effectiveness of staff interacting with it.
Even before a sample is obtained things can go wrong. Failing to ensure that the patient is properly informed of the reasons for investigation can lead to their not attending for testing. Neglecting to check that a patient has attended for testing can lead to further delays – particularly where a GP has a high index of suspicion about systems or previous experience with the patient not attending for review. These can all lead to criticism when a patient is negatively impacted.
Lesson: Clinicians should ensure that where necessary they hold (and document) a full discussion with the patient when the need for testing is identified. Individual patient needs and circumstances should be taken into account in coming to a decision about the need for more active follow-up.
When results are returned to the practice there can be delays in viewing and actioning these due to factors such as clinician holidays, part-time working and overload. These delays can be problematic if the result requires immediate action – particularly with a combination of results which, when viewed together, would prompt action. Systems in which different doctors view different results for the same patient on different days can also result in a missed opportunity to avoid delay. This can occur in practices which operate a duty doctor system.
Lesson: There should be a process in place to ensure that the most appropriate clinician views results within a reasonable timescale – and if this is not possible, another clinician should screen the results in the interim for anything urgent.
Delays or failures to refer the patient for specialist review
Multi-disciplinary or multi-agency care where records are not shared can cause referral delays as the pieces in the jigsaw are often not effectively put together.
Lesson: Clinicians should undertake to meet with other healthcare professionals, such as health visitors and district nurses, to ensure the effectiveness of communication mechanisms is maximised, responsibilities are clear and records shared where possible.
The MDDUS risk team is now completing a similar analysis on private hospital and dental claims and more information on these will follow soon. We have also developed a range of risk checklists which members and their teams can use together to identify and mitigate their own risks.
Liz Price is a risk adviser at MDDUS