These cases are based on actual calls made to MDDUS advisers and are published here to highlight common challenges within practice management. Details have been changed to maintain confidentiality.
VAPING IN THE SURGERY
Q A nurse has advised us that an associate dentist in our practice has been vaping in the consulting room between patients. Are we allowed, on legal grounds, to demand that she stop this behaviour?
A UK law prohibits cigarette smoking in enclosed public places and workplaces but the laws do not cover vaping. Organisations are free to make their own policy on the use of e-cigarettes on their premises. The practice should have a non-smoking policy in place and this could be extended to cover vaping. If you have no policy on smoking, a good place to insert one is in the drugs and alcohol policy. Any changes to the existing policy should be communicated to practice staff in writing. Practices should also ensure that their smoking policy is kept separate from the employment contract and details are provided in an employee handbook. This will allow the policy to be amended without having to get employees’ agreement to amend their contract. Public Health England has published framework advicefor businesses and employers to help createpolicies on the use of e-cigarettes.
PRE-ADOPTION RECORDS REQUEST
Q We have a three-year-old patient whose adoptive mother would like to access his pre-adoptive medical notes to obtain information relating to complications during pregnancy and childbirth. She is keen in particular to gain further information about alcohol consumption during the pregnancy. The mother states she was not provided a medical history for the child from social services.
A Adoptive parents take on parental responsibility and can therefore request access to a child’s medical notes. The adopted child will be given a new NHS number and all previous medical information relating to that child is put into a newly created medical record. The new medical record should therefore contain all relevant information about the child’s previous treatment in primary and secondary care but must not contain any information relating to the identity or whereabouts of the birth parents. The pre-adoptive information is regarded as confidential and any relevant medical information should have been shared with the new parent by social services during the adoption process. The scenario set out here presents a difficult situation for both the surgery and the mother and you may wish to emphasise the importance of keeping the pre-adoption notes confidential. You should urge the mother to discuss her concerns with social services who may be able to access the information she desires without breaching the birth mother’s confidentiality. The adoptive mother should also be encouraged to discuss any concerns about the child’s health or development with the GPs in the practice for further advice and assessment.
STUDENT NURSE INDEMNITY
Q Our practice has agreed to take a student nurse on placement from a local university. The individual will be monitored by our practice nurse and will only consult with patients under supervision. We are an MDDUS discount practice scheme. Can you confirm your position regarding indemnity for the student nurse?
A A student nurse acting in accordance with the duties delegated by an employee of the practice will have access to indemnity through the vicarious liability of MDDUS GP partners. MDDUS does not indemnify individual student nurses and it is possible that they could be sued in their own right and may consider obtaining personal indemnity for complete peace of mind. The university or employing trust is likely to retain a degree of vicarious liability for the student nurse and MDDUS would reserve the right to pursue any third party for a contribution if we consider it appropriate.
Q Last year a 91-year-old female patient of the practice left an envelope at reception containing £500 in cash. An accompanying note said the money was a donation to help spruce up the waiting area for other patients. Apart from some minor memory issues there appear to be no acute concerns regarding the patient’s capacity. The practice accepted the gift and used it to repaint the reception area. Recently she left another envelope, again with £500. Should we keep accepting these donations?
A The GMC states in Good Medical Practice that a doctor may accept unsolicited gifts from patients or relatives but should consider whether by doing so they are altering their relationship with the patient, and also how this may be perceived by the public in general. The regulator provides supplementary guidance in regard to financial and commercial arrangements and potential conflicts of interest, which is available at www.gmc-org.uk. The practice should be satisfied that all actions taken are in accordance with such guidance and must be prepared to explain and justify any decisions made and actions taken. The acceptance of gifts by general practitioners is also subject to statutory and contractual regulations. The General Medical Services Contract Regulations highlight that a register should be kept of gifts received of a value in excess of £100, unless the gift is unconnected with their professional services. This register should include details of the donor and the nature of the gift, including whether it was given to the practice or an individual.
SISTER ON THE LIST
Q Our practice is in a rural area and it has recently come to my attention that the practice nurse has a sister who is registered as a patient. The nurse has assured me that she is aware of the legal requirements in regard to patient confidentiality and that she would never access her sister’s medical records inappropriately. What is the legal/ethical position on having family members of staff registered at the practice?
A The Nursing and Midwifery Council Code states that nurses should "stay objective and have clear professional boundaries at all times with people in your care". GMC guidance (Good Medical Practice) is more specific on the treatment of family members, stating that: “Wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship”. It would be preferable for the sister to be registered elsewhere but if this is not possible then the practice should ensure that the nurse is not providing direct care and also that a strict policy with regard to accessing medical records is adhered to by all employees to ensure confidentiality. Patient systems can also be setup to alert the PM to staff accessing particular patient records - e.g. those designated as family members at point of registration.
Q A child from a large family in our practice recently died in an accident. The local child death co-ordinator has now requested that the practice disclose the child’s medical records (including concerns about safeguarding) to the safeguarding team. The team have not obtained parental consent for the release of the records as they are relying on the provisions of the Crime and Disorder Act 1998 in order to prevent serious harm to a child or young person. We are aware of no concerns regarding the safety of the other children in the family and are thus unsure why the disclosure is necessary. Can you advise?
A The GMC states that doctors must co-operate with any investigations regarding the safety or welfare of a child or young person. Perhaps the safeguarding team is investigating factors leading to the child’s death, as well as further concerns for the safety of the other children in the family. In any case it would be helpful for the practice to have more information. A data controller is entitled to request this in order to be satisfied that disclosure in the absence of consent from a personal representative of the deceased is appropriate. You should reassure the safeguarding team of your willingness to co-operate in the investigation but state that you also require sufficient details to determine what information-sharing is appropriate. If the safeguarding team believes that parental consent is not required they would need to explain why consent has not been sought. Should you judge that disclosure of the information requested is in the public interest, this disclosure should be of the minimum necessary and relevant to the purpose. Your local Caldicott Guardian may be able to advise you with any further concerns.
Q A 52-year-old patient has been in touch with the practice asking for one of the GPs to fill in a medical certificate. She plans to take part in a charity challenge which includes cycling over rough terrain for several days and needs to be certified fit. We are worried about being held liable should anything go wrong. A Doctors must be cautious when completing fitness certificates. Even if the patient has been thoroughly examined, appears healthy and has no history of health problems that would cause concern, this is no guarantee of future fitness. The GP must be sure to act within their expertise and knowledge and be able to justify what they have written should they later be questioned. It may be advisable to make a broad statement along the lines of: “Based on the information available in the patient’s medical notes, there appears to be no contraindication to exercise but, given the nature of the event, a sport medicine specialist with knowledge of the event would be better placed to comment on the specific query raised".
REFUSING TO PAY
Q We have a patient who is dissatisfied with her upper partial denture after having consented to treatment and costings. She is now refusing to pay though seems happy enough to keep the denture. Our experience in chasing such patients has been singularly unsuccessful and I have advised the dentist to let it go but he is adamant we pursue the debt. Would it be wise to chase and how can we prevent this from happening in future?
A Pursuance of outstanding payments can be a long and frustrating business but writing off such debts is equally disappointing. You might consider contacting the patient again to offer a further review to discuss any problems and make adjustments. You could also instigate the normal practice protocol of reminder letters before consideration of forwarding to a debt collection agency for recovery of the money. To prevent this happening in the future you might consider instigating staged payments each time the patient attends for treatment, thus making sure that a significant amount is paid before treatment is completed.