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 disgruntled patient who has decided to leave our practice recently requested a copy of his medical records. We provided these and he has now submitted an angry written complaint over an entry made a year ago in relation to what the patient states is an erroneous diagnosis. He disputes the entry and wants it removed before his records are transferred. How should we respond?
A Both the Data Protection Act (DPA) and the General Medical Council (GMC) state that a doctor’s clinical opinion should remain in the notes if it was a reasonably held belief at the time and is relevant to the patient’s care. A patient who disagrees with such an entry is entitled to add their own annotation to the records in response. In this case a letter providing the patient clarification of your position on the matter and informing him of his rights in the matter would be reasonble. You should also advise the patient that if dissatisfied with your response he can contact the ombudsman or the Information Commissioner’s Office, which handles compliance with the Data Protection Act.
DENTAL INDEMNITY EXCLUSIONS
Q One of our staff recently saw a notice from the BDA urging dentists to check the small print on their indemnity policies to ensure they are appropriately covered. The warning involved a recent GDC case in which the adequacy of a registrant’s cover was questioned as the policy contained exclusions relating to the transmission of blood-borne diseases. Does your standard indemnity policy include such exclusions?
AWe have been contacted by a number of dental members in regard to this issue. The case apparently led a GDC panel to conclude that the registrant’s policy did not fulfil Standard 1.8 within Standards for the Dental Team: “You must have appropriate arrangements in place for patients to seek compensation if they suffer harm”. Our standard indemnity policies at MDDUS do not include exclusions for specific risks such as failure to prevent the transmission of blood-borne diseases.
QWe have a large number of patients due to come in soon for their flu jab. One of our nurses has just gone off sick and is not expected back for a couple of months. Can our healthcare assistant (HCA) step in and help? She has the appropriate training.
A Many HCAs are well-trained and competent to administer vaccinations, but it is the prescribing of the vaccine, and the assessment of the patient prior to that, which is the issue. The majority of NHS flu vaccinations provided are prescribed via patient group directives (PGDs). These are written instructions for the supply and/or administration of a named licensed medicine for a defined clinical condition to groups of patients, who may not be individually identified before presentation for treatment. PGDs are not a form of prescribing but provide a legal framework for nurses and certain other registered healthcare professionals to administer a medicine directly to patients under a specified criteria, without the need to see a doctor or other qualified prescriber. However, please note that HCAs may not administer drugs or provide treatment under a PGD. For an HCA to be involved in flu immunisations it must be via a patient specific directive (PSD). A PSD is a written instruction from an independent prescriber (doctor, dentist or independent nurse prescriber) to another healthcare professional, to supply and/or administer a medicine directly to a named patient or to several named patients. PSDs are used once a patient has been assessed by a prescriber. This assessment should be documented and contemporaneous to the administration of the vaccine.
ADVICE FROM ABROAD
Q Our medical practice has been receiving an increasing number of calls from patients while abroad on holiday or business. We operate a triage system so patients are accustomed to telephone advice. Our policy has always been not to offer overseas call-backs on the grounds of cost but now calls to mobiles are no more expensive than those within the UK. However, we are still concerned that in advising patients not currently present in the UK we may be offering a service that is not indemnified. Can you advise?
A If a patient contacts the surgery for assistance whilst outside the UK, it is important to understand the associated risks. Administrative requests (such as for a repeat prescription due upon their return or for an appointment) can usually be responded to in the normal manner. But when a patient is requesting medical advice, it is very important to be aware of the obvious risks in being unable to assess the patient properly in order to make a diagnosis – and also the increased risks associated with treating patients in other countries. MDDUS is a UK wide indemnity organisation and provides assistance to members for actions raised against them within the UK. Members would NOT be represented if action was taken against them in another country where harm had arisen as a result of their provision of advice. Because of this, we would strongly advise that members do not offer any medical advice in relation to a non-recurrent illness to a patient who is overseas, but that they encourage that patient to see a local medical practitioner.
ACCESSING TWIN RECORDS
Q Our practice has two patients who are twin girls age 12. Mum and Dad are divorced but both share parental responsibility. We have received a request from Dad to come into the practice to view the twins’ medical records. He has since remarried and wants to bring his new wife – a qualified nurse – with him to review the records. Are the twins old enough to consent to this or do we need to contact Mum for permission?
A All children with “capacity to consent” have the right to allow or prevent access to their medical records. In England there is a presumption of capacity at the age of 16 but children will often have capacity for many decisions before this age. You should first establish if either of the twins has the capacity to decide whether their father and, secondly, their stepmother can have access to their notes. We would suggest you talk to both girls separately to determine whether they understand the nature of the disclosure, its purpose and any possible consequences. A child will have capacity if they are able to understand and retain this information, weigh it up and then communicate their decision. Should each individual girl be judged to have capacity and agree to her notes being disclosed to her father and stepmother then you may do so, subject to redaction of third party or significantly harmful information. Should either girl refuse to consent you should respect her wishes, unless you feel she or someone else would be at risk of serious harm if you did not disclose relevant information. In the latter situation we would recommend seeking further and more specific advice from MDDUS prior to disclosure.
Q Our receptionist is a former dental nurse and, because of her experience and knowledge, she is able to respond to some dental queries from patients. Should she be registered with the General Dental Council?
A Registration with the GDC is only required for those who wish to work as a dentist or dental care professional in the UK. This would not normally include the work of practice receptionists. However, you should have clear policies and protocols that detail what she can and cannot say to patients so that she does not stray into what could be classified as the practice of dentistry.
Q Our practice has in recent years seen a rise in incidents involving rude and abusive patients. Could you advise on a standard template letter we could send to such patients setting out our zero tolerance policy and with a warning about possible removal from the patient list?
A In recent years, use of the term ‘zero tolerance’ has come under increasing criticism in the NHS, as it does not take into account behaviours that may be explained or mitigated through mental illness and other disorders, challenging behaviours in learning disabilities and other contributory factors. ‘Zero tolerance’ approaches may also fail to consider personal thresholds for unacceptable behaviour. What may be offensive or unacceptable to one member of staff may be viewed as understandable or tolerable by another. What’s important is that organisational policy recognises that it is the individual’s perception of what is acceptable or unacceptable that is important. We would suggest using different terminology in referring to your policy, such as ‘unacceptable behaviour’. In regard to warning letters we would advise that the wording of warning letters needs to be considered on an individual basis depending on the patient and the nature of the inappropriate behaviour. Warning letters should be detailed, setting out the specific issues, incidents and dates involved. It would also be reasonable to acknowledge that there may be some reason for the patient’s behaviour: e.g. “I understand it may be frustrating when you don’t receive the service you would like but…” adding that this cannot justify inappropriate behaviour and that staff have a right to work without being abused, as set out in your practice policy. Be aware that the GMS contract stipulates that a patient should have had a warning in the last 12 months before being removed to give them a chance to change their behaviour. Exceptions to the need for a warning include patients moving out of the practice area or if it is considered that a warning may put the patient or others at risk. The letter should also set out steps for the provision of alternative care in the event of removal from the list. More guidance is available from the GMC.
Q A patient came into the practice yesterday to pick up a prescription but later discovered she had been given one belonging to someone else. She has made a complaint about it. What should I do?
A The first step would be to draft an appropriate response, including an apology for what is clearly a breach of confidentiality. An MDDUS adviser can offer detailed advice on the wording of the response, but you should explain how the incident occurred and set out the steps the practice will take to ensure it does not happen again. It may be advisable to conduct a significant event analysis to review what happened and highlight any weak points in the practice’s processes that need to be addressed. You should also contact the patient whose prescription was disclosed in error to inform them of the breach, offering a similar apology, explanation and details of how the practice will change. The breach should be recorded through the NHS Digital Toolkit as is required for general practices in England (elsewhere the practice should consider whether the ICO should be notified, based on the seriousness and significance of the breach).