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 GP in our practice has cared for an elderly gentleman for the last few years while under treatment for cancer. He is now receiving palliative care. Last week the GP received a watch in the post with a note thanking him for all he had done for the patient. An enclosed receipt revealed the watch cost over £400 pounds. The practice partners are happy for the GP to keep the watch and the patient would be upset if it was returned. Are there any probity issues in accepting the gift?
A GMC guidance states that accepting a gift is allowed, provided it does not affect or appear to affect the way a patient is treated and there has been no influence applied to pressure the patient into offering the gift. It cautions in general that any doctor receiving a gift or bequest must always consider the potential damage this might cause to the patient’s trust in the doctor or the public’s trust in the profession. Doctors should refuse gifts or bequests where they could be perceived as an abuse of this trust. Given these requirements are fulfilled, accepting the watch as a genuine token of gratitude could be reasonable. The only other matter to consider is registering the gift in line with Performers List regulations. Gifts with a value of over £50 should be entered on a practice gift register along with the name of the patient, doctor and approximate value.
Q A patient with mental health problems has attended the practice several times in the past few months for consultations with our nursing team. On the last three occasions he has spoken in detail about his sexual activity and it is upsetting our nurses, so much so that they are very uncomfortable about seeing him again. We are considering removing him from the practice list – what steps should we take?
A Removing any patient from your list is an emotive issue and one that requires careful consideration. In its guidance, Ending your professional relationship with a patient, the GMC advises: “You should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient.” This may occur where the patient has become violent, abusive or threatening, or has made sexual advances. Before making a decision, the regulator sets out four steps to follow: warn the patient you are considering ending the professional relationship (a formal written warning would be appropriate); do what you can to restore the relationship; explore alternatives to ending the professional relationship; and discuss the situation with an experienced colleague or your employer/ contracting body. It would be useful to discuss the issue as a practice, noting what is said and what decision is made. Perhaps you might explore other options with the patient such as agreeing conditions in which a chaperone is present – but if you decide to remove the patient ensure this is in full compliance with GMC guidance. Be prepared to justify your decision and ensure prompt arrangements are made for the patient’s continuing care.
Q One of our receptionists is planning to adopt her grandson. She has been with us for four years and works two mornings per week so her salary is below the Government’s lower earnings limit of £112 per week. Is she entitled to adoption pay or leave?
A Adoption leave/pay does not apply in situations where a family member (or indeed a stepchild) is being adopted, so in this instance your receptionist would not be eligible. In addition, to qualify for statutory adoption leave, employees must earn on average at least £112 per week (before tax).
Q A couple of our staff members are smokers and sometimes choose to smoke in the practice car park. This looks unprofessional – can we tell them to stop doing this, or are they entitled to smoke outside where they like?
A The short answer is yes, you can tell them to stop smoking in the car park. The law entitles employees to an uninterrupted rest break of 20 minutes when their daily working time is six hours or more. But employers are not obliged to provide smoke breaks or outside smoking areas. It may be useful to have a policy stating where smoking is allowed on practice property (perhaps in the rear of the premises). Any policy would of course be in addition to the relevant government smoke-free legislation that applies in your area. Generally, this prohibits smoking in wholly or substantially enclosed public places. Try to be positive in seeking solutions, balancing the need to encourage healthy behaviour with possibly alienating valuable staff.
Q One of our patients transitioned to female last year. She recently came into the surgery complaining of ear pain and was referred to ENT for further examination and treatment. Details of her gender surgery were automatically included in the electronic referral, which she was very unhappy about. How should we handle referrals like this in future?
A It is unlawful in some circumstances to disclose a patient’s gender history without their consent. GMC guidance advises healthcare professionals they must make sure any personal information held about patients is effectively protected at all times against improper disclosure. You should respect the wishes of any patient who objects to particular personal information being shared with the healthcare team or with others providing care, unless disclosure would be justified in the public interest. The regulator goes on to say that, when communicating with other health professionals, gender history need not be revealed unless it is directly relevant to the condition or its likely treatment. In the case of ear pain, it would not be appropriate to disclose details of gender surgery. Practices must always be wary of electronic referral templates that automatically include high-priority clinical information and be prepared to manually remove anything that is not relevant (or which the patient has asked not to be disclosed). More information is available in the Advice for doctors treating transgender patients section of the GMC website – and see also the article on page 12 of this issue.
QAccording to the Information Commissioner’s guidance Subject access code of practice (tinyurl.com/oksakle) you may charge a fee of between £10 and £50 for complying with a SAR relating to health records. The exact amount depends on how the health records are held. In this case, the guidance states you may charge up to £10 for complying with a SAR relating to health records if they are held only electronically. This would cover, for example, the costs of printing out the requested information. The higher charge can be made for records that are held either wholly or partly in nonelectronic form. Be sure to also comply with standard Data Protection Act rules relating to issues such as non-disclosure of third party information or information that could cause serious harm.
Q We recently hired an admin assistant who lives in the local area. During routine checks we discovered she has accessed the health records of her uncle and we suspect also a number of her friends. She has been dismissed and we have informed her uncle about the incident. Should we also inform the other data subjects that there has been a possible breach?
A It would be advisable for senior practice staff to hold a significant event analysis (SEA) meeting as soon as possible to review what happened. You should carefully review relevant guidance – for example, the Information Commissioner’s Office (ICO) website has a section on health which provides useful information on responding to data breaches across all four UK countries. This includes information and links on how to report incidents. In England, healthcare organisations must now use the IG Toolkit Incident Reporting Tool which will report all information governance serious incidents requiring investigation (IG SIRIs) to NHS Digital, the Department of Health, the ICO and other regulators. In Scotland, Wales and Northern Ireland reports are submitted to the ICO using its security breach notification form. You can contact the ICO helpline to discuss the incident and for guidance on whether you should inform the patients whose records have potentially been breached. As always, you should carefully document all discussions, including rationales for decisions that are made.
Q How long is our general practice required to keep paper records of old resolved patient complaints and should these be stored separately from the medical notes?
A NHS guidance states that a formal patient complaint file in England should be stored 10 years from the date of resolution and then reviewed to determine if no longer relevant before being destroyed. In Scotland a complaint file should be stored for seven years and, in children, until the patient is age 16. Complaint files are normally stored separately and only information that is relevant to ongoing care should be copied into the clinical file – but there should be a reference (flag) that a complaint folder exists..
DELEGATING INR MONITORING
Q We are a DPS (discount practice scheme) practice with MDDUS. A number of our patients are on warfarin and we would like to know if it would be appropriate for our healthcare assistants (HCAs) to use a portable INR monitor and advise patients on doses based on the results.p>
A Practice staff in discount schemes are normally vicariously indemnified but MDDUS expects that for any appropriately delegated tasks, HCAs will be adequately trained and supervised and adhere to best practice and guidance. Monitoring of INR and warfarin dosage can be complicated and getting it wrong can have serious consequences for patients and for the practice with the risk of a claim or GMC referral. Monitoring by HCAs might best be restricted to confirming stable INR status and a continued warfarin dose. Any change in INR should normally be referred to the prescriber – be that a practice nurse or doctor – for assessment of possible dose change and to instruct on scheduled review. The GMC makes clear in its guidance on Delegation and referral that: “When you delegate care you are still responsible for the overall management of the patient.”