Chaperone essential

INTIMATE physical examinations – those of the breast, genitals and rectum – are a routine part of clinical assessment and diagnosis for many clinicians but can be embarrassing and uncomfortable for patients. It is necessary to offer a chaperone for patient reassurance and also protection and medico-legal cover for both the patient and the doctor.

Awareness of the need to offer a chaperone was emphasised by the case of Dr Clifford Ayling. In 2000 Ayling was convicted of 13 counts of indecent assault on female patients in his care. Following a public inquiry in 2004 into the misconduct of this criminal doctor, there was an increased call for the greater use of chaperones by several professional bodies, including the GMC and various medical defence organisations.

Recommendations from the inquiry regarding the use of chaperones were made in a subsequent report and aimed at trusts, encouraging them to develop chaperone policies and also instructing proper chaperone use among individual doctors. Allegations similar to those made against Ayling have been continually reported to the GMC. An FOI request made to the regulator in 2009 revealed that 35 complaints were attributed to inadequate chaperone use from March 2006 to August 2009, and MDDUS deals with numerous complaints and claims each year.

Protecting patients and doctors

Despite this, many doctors are still not regularly using chaperones for examinations and a study by Metcalfe in 2010¹ showed that almost half of acute NHS trusts in England had yet to initiate a chaperone policy. When chaperones were used, the vast majority of doctors did not record their use². Together these put patients at risk of assault and doctors liable to medico-legal proceedings.

The number of trusts with a chaperone policy has increased since the publication of the Ayling inquiry but by 2010 many trusts still did not have a policy nor did they intend to put one in place. There may be several reasons for the lack of implementation such as: increasing financial difficulties, lack of awareness or interest in applying the Ayling recommendations and the continued perceived belief that there is nothing wrong with the morals and actions of most doctors, thus a chaperone policy is not required. However, a policy can minimise the expense incurred in following-up complaints relating to the lack of a chaperone and reduce the number of complaints made at a local and GMC level.

The topic of chaperones is becoming increasingly relevant in this litigious and health-and-safety-conscious era and it should be recognised that chaperones are not only for patient protection. The provision of a chaperone policy is an inexpensive, comprehensive way of addressing patient and doctor safety during consultations. All trusts should implement a chaperone policy and resource the policy efficiently, including staff training and advertising.

Of the trusts which already have a chaperone policy, patients are commonly informed verbally during their consultations. However, using methods such as leaflets and posters in clinic waiting rooms would allow patients to consider their options beforehand. This may also increase chaperone use among consultants as it does not solely rely on the doctor remembering to offer a chaperone.

Gender and other issues

Another 2010 study of consultant use of chaperones2 revealed that, at an individual level, chaperone use among consultants was not consistent from patient to patient, particularly for male patients. In a hospital setting, doctors who routinely conducted intimate examinations consistently used chaperones for female patients but it was as low as 28 per cent for male examinations, though there was a wide variation between hospital specialties. Examining physicians were less likely to offer a chaperone if the patient was male which may be why male intimate exams are frequently performed without a chaperone.

The higher use of chaperones for female patients may indicate there is a perception that these examinations are ‘high risk’ and thus doctors are more cautious. Regardless of the reasons, all doctors should make sure to offer a chaperone to every patient and not discriminate between genders.

Despite many trusts not having a formal chaperone policy, 97 per cent of consultants reported that a chaperone was ‘always’ or ‘usually’ available and cited other healthcare professionals as appropriate chaperones2. Consultants also agreed that chaperones should be trained and most importantly it was recognised that administrative staff are not suitable, which corresponds with GMC guidance. However, the documentation surrounding chaperone use was poor with 80 per cent of consultants not documenting the presence of a chaperone including their name and identity. Irrespective of whether a chaperone is present or used, the offer should be documented in the patient notes.

In general practice the pattern is similar, although overall chaperone use is lower. There are two factors that likely influence chaperone use in primary care: (1) the availability of another healthcare professional and (2) the gender of the GP³. In the community it is less likely that another healthcare professional would be available to chaperone an exam and there is also the 10-minute time constraint put on GPs during consultation which together hinder the ideal use of chaperones. When GPs use chaperones for an intimate exam on a patient of the opposite sex, male GPs are more likely to use a chaperone than female GPs⁴. Overall there is more caution taken for female patients and particularly by male GPs.

GMC guidance

Recently updated GMC guidance – Intimate examinations and chaperones (2013) – recommends that a patient should be offered a chaperone whenever there is a need to carry out an intimate exam. Key points from the guidance include:

• A chaperone should be offered regardless of the gender of the doctor or the patient.

• Patients should be reminded that chaperones are confidential.

• Any discussion of chaperones should be documented in the patient notes even if the offer is declined. If a chaperone is present, their name and identity should be recorded.

• A trained healthcare professional is the ideal chaperone and they should be present and witness the whole exam. Receptionists and administrative staff, for example, are not suitable.

• Friends and family members are usually not suitable as chaperones because they are not impartial or bound by confidentiality but they may be permitted if the patient desires and the doctor is comfortable to proceed.

• Because friends and relatives don’t offer the doctor protection, then a possible solution is to request a healthcare professional to chaperone as well if you are concerned.

In conclusion…

The number of chaperone policies has increased and chaperone use among doctors is good but there are deficiencies in some areas and improvements could still be made in the offering and recording of chaperones. GMC guidance and the Ayling Inquiry recommendations have not yet been fully integrated into clinical practice which is leaving doctors and patients vulnerable but it is hoped that in realising the importance of a chaperone and understanding the available guidance that this can be overcome.

Neil Metcalfe is a practising GP in York and Nathan Griffiths is a medical student at Manchester Medical School

References:

1. Metcalfe NH, Moores KL, Murphy NP, Pring DW. The extent to which chaperone policies are used in acute hospital trusts in England. Postgrad Med J 2010;86(1021): 636-640.
2. Moore KL, Metcalfe NH, Pring DW. Chaperones and intimate physical examinations: consultant practice and views on chaperones. Clin Govern Int J 2010;15(3): 210-219.
3. Price DH, Tracy CS, Upshur RE. Chaperone use during intimate examinations in primary care: postal survey of family physicians. BMC Fam Pract 2005;6: 52
4. Conway S, Harvey I. Use and offering of chaperones by general practitioners: postal questionnaire survey in Norfolk. BMJ 2005;330(7485): 235-236.