These cases are based on actual advice 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 PM is reviewing the practice’s chaperone policy and has found that, for intimate examinations involving a doctor and patient of the same gender, a chaperone is not routinely offered. The practice is often short-staffed and the manager asks MDDUS if the offer of a chaperone is essential for these same-sex consultations.
A MDDUS has handled a number of cases where a patient undergoing an intimate examination with a doctor of the same gender has complained about not being offered a chaperone. Finding a suitable chaperone for intimate examinations can put practice resources under pressure, but GMC guidance clearly states: “When you carry out an intimate examination, you should offer the patient the option of having an impartial observer (a chaperone) present wherever possible. This applies whether or not you are the same gender as the patient.” Chaperones should stay for the whole examination and, where practicable, be able to see what the doctor is doing. The chaperone does not have to be medically qualified but should have received appropriate training to understand what constitutes a normal examination and must be respectful of the patient’s dignity and confidentiality.
Q A dentist suspects his receptionist may have stolen a number of patient records from the practice. Relations between the pair have been strained for several weeks after the receptionist was disciplined, and he has recently made comments about “getting even”. The dentist is unsure of what to do if the records have indeed been stolen.
A The first step is to check if the records have been misfiled, rather than stolen from the practice. If you are sure they have been deliberately and inappropriately removed then ideally the practice would have in place a policy on dealing with a data security breach. This will include informing the patients concerned in writing and alerting the Information Commissioner’s Office. The ICO identifies four key steps in a breach management plan: containment and recovery; assessment of ongoing risk; notification of breach; and evaluation and response. More detailed advice is available from MDDUS and from ico.org.uk
RIGHTS OF ACCESS
Q The father of a six-year-old patient wants to access his son’s medical records to check a prescription for a minor infection as the boy is staying for the weekend. The practice manager is aware the man is estranged from the boy’s mother and that she doesn’t want him to access their son’s notes. She asks MDDUS how to proceed.
A A key element to consider before allowing access to records is whether the child’s father has parental responsibility. While all mothers are automatically deemed to have parental responsibility, not all fathers do. A father acquires parental responsibility if married to the mother at the time of birth (or conception in Scotland). An unmarried father only has parental responsibility if it is recorded on the birth certificate at registration (since 1 December 2003 in England or Wales, 15 April 2002 in Northern Ireland and 4 May 2006 in Scotland). An unmarried father can acquire parental responsibility by legal agreement with the mother or by applying for a court order. The same laws apply to step-parents and civil partners. If the father’s name is not on the birth certificate and he has not been granted parental rights by agreement or by court, then he is not entitled to access the records. If he is entitled, be sure that allowing access is not against the child’s best interests. Any third party information should also be redacted from the notes.
Q The mother of a young girl is refusing consent for her daughter to be given the MMR vaccine, preferring instead a homeopathic treatment. The GP is concerned that this would not be in the child’s best interests and also fears being held to account should the girl subsequently fall ill.
A Parents have the right to refuse vaccinations for their child and GPs should respect their decision. However, with such an important decision, consider involving both parents in the discussion. Be sure to clearly explain the risks and benefits of immunisation – leaflets or other learning materials may be a useful aid. If the parent(s) cannot be persuaded then make a detailed note of the discussion in the child’s medical record.
Q A dental nurse volunteers for a local support group for people who suffer from dental phobias and anxiety. She occasionally talks to patients in the practice about it and wants to access the practice database to find their contact details and send out information about the group’s work.
A Despite the nurse’s good intentions, accessing the practice’s systems to find patient contact details for this purpose would breach confidentiality. It would also be a breach of the Data Protection Act as personal information should only be used to provide patients with dental care or to inform them of services your practice provides. It should not be used to inform them of non-dental products, meetings or services. Make sure all staff are clear about who can access data and for what purposes.
Q The practice will be closed for an upcoming bank holiday weekend and the manager is concerned about the disruption that could be caused to patients, particularly as there were issues with the management of test results during the last holiday closure. She asks MDDUS for advice.
A With any holiday closure, planning ahead is key. On the day or two before the practice closes staff should be vigilant in relation to any abnormal result handling. Complaints can often arise in this area, particularly regarding issues like warfarin results or electrolyte abnormalities that may require more urgent attention. Clear, accurate and contemporaneous record keeping is essential, as always. Let your patients know about the closure – via the noticeboard, face-to-face or on the practice’s website/social media pages. Patients on repeat prescriptions should be given a reminder to allow them to pick up any repeats before the long weekend. Prescription counter slips can also carry a special notice so that patients can make sure they have adequate supplies of repeat medication.
GAMES TIME OFF
Q A number of practice staff have tickets for the Commonwealth Games and have requested time off to attend. The manager cannot accommodate all the requests and asks MDDUS how to proceed.
A Check how many staff want time off and then compare that to the practice’s staffing needs. There is no legal obligation for you to grant all requests, but be sure to follow practice policy and be consistent, fair and transparent. Options for staff include taking annual leave, making up time at a later date, allowing flexible working during the event or granting special paid/unpaid leave. A lottery system of picking names out of a hat could help when you cannot accommodate all requests. When refusing requests, give at least one day’s advance notice for every day of leave requested, i.e. two days’ notice if refusing a request for two days’ holiday. You should also make it clear that unauthorised absence will constitute misconduct and could lead to disciplinary proceedings.
Q A patient explains his car has been hit by a taxi while it was in the practice car park. He is looking for potential witnesses to support his insurance claim and has requested a list of all patients who attended the practice that day around the time of the accident. The manager wants to help but is conscious of data protection rules. She adds that a disclaimer sign is displayed in the car park, stating that vehicles are left there at their own risk.
A Under the Data Protection Act you cannot reveal the contact details of patients for this purpose. The General Medical Council allows disclosure only where a serious crime has been committed. As with any minor road traffic accident, it would be the driver’s responsibility to obtain the details of witnesses at the time. If a patient contacts you to say they witnessed the incident then you could invite them to contact the driver directly. You may sympathise with your patient but you are not required to help him with this issue.
ENTITLED TO CARE
Q A patient has been undergoing cancer treatment for several weeks and her GP has referred her for hospital treatment. However it has since come to light that she is a failed asylum seeker and, as such, is not entitled to free NHS care. The hospital has contacted the practice manager to confirm that, given the patient’s illegal status, the practice will fund her care.
A An MDDUS adviser agrees that it would be unreasonable to expect the practice to fund the patient’s secondary care. The practice should continue providing any immediate necessary treatment and the PM should contact the local clinical commissioning group (CCG) to clarify what this level of treatment would involve. The CCG should also be able to explain who is responsible for the cost of providing the patient’s care. Until this decision is made, the practice should continue to keep the woman on their list and to meet her clinical needs as far as possible under the circumstances. The adviser also cautions the PM that MDDUS has defended cases on behalf of members where refusing or delaying treatment on the basis of eligibility has led to claims of negligence.
Q A patient has been repeatedly rude and aggressive towards staff in the past few months, on one occasion insisting he only wanted to see a “male white doctor”. He also shouted at reception staff and has been refusing to take his prescribed medication. The PM wants to remove him from the practice list and asks MDDUS for advice.
A GMC guidance advises that deregistration should be a rare event prompted, for example, by a patient being threatening, abusive or violent, persistently acting inconsiderately or unreasonably, stealing from the premises or making sexual advances towards a doctor/staff member. Before ending your relationship you should warn the patient in writing, highlighting his unacceptable behaviour – citing incident dates and details where appropriate – and advising that he may be deregistered if there are any further incidents. Include only relevant incidents – a failure to comply with treatment is not a valid reason for considering removal. Do what you can to restore the relationship with him and explore alternatives before deciding whether to remove him from your list. MDDUS is happy to review a draft letter before you send it to the patient.