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.
ANTENATAL CARE AS SICK LEAVE
Q A part-time member of our practice staff is pregnant and all of her antenatal appointments are on a day that she is at work. We are setting up our regular rota to cover the busy Christmas period and would prefer her to work on regular “in” days. Is it a reasonable request to ask that she rearrange her antenatal appointment for another day? We always give such appointments for staff as paid leave. Is this standard practice or should it be classed as sick leave?
A In general terms an antenatal appointment should be paid and would not be classed as sick leave. You can ask for evidence of the appointment and whether it can be rescheduled but you should make it clear that if rescheduling is not possible then the original time and date will be honoured and she will have the right to take the time off when it suits.
GAP IN GDC REGISTRATION
Q Our dental practice recently hired a dental nurse who has only just completed her training. She has applied to the GDC register. Is it possible for her to work in the practice before her registration is in place?
A The GDC has confirmed that a dental nurse in this situation can continue to work, provided the same supervision is in place as that which existed during training. GDC guidance states: “A named GDC supervising registrant must take full responsibility for providing direct supervision of the individual trainee. However, according to the ability and progress of the trainee, supervision may be delegated (if appropriate) to other GDC registrants. The named supervising registrant will continue to be accountable overall for the trainee. The employer must ensure that the individual trainee keeps a log book of training they receive (including induction), which is regularly signed off by the designated supervisor.”
RETAIN RECORD REQUESTS?
Q Is our medical practice required to keep/scan requests from solicitors for copies of patient records and from insurance companies for reports?
A A patient’s medical records should contain only relevant information for the ongoing care of that patient. Administrative requests can be stored separately, with reference to such documentation in the medical records in the unlikely event they may be required in future.
NON-MEDICAL MEDICINES MANAGER
Q Our practice has a non-medical member of staff who processes all repeat prescriptions. Would she be allowed to add or make changes to medication following recommendations received from hospital letters, if done under adequate supervision from a practice GP?
A In approaching such a decision you should be mindful of GMC guidance on delegation (Good Medical Practice), which reminds doctors that when delegating the care of patients to a colleague they must be satisfied that this person has the appropriate qualifications, skills and experience to provide safe ongoing care for that patient. It is therefore important that clinicians are satisfied that the medicines manager is competent to undertake this role. The GMC also states that doctors must prescribe medicines, including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the medications serve the patient’s needs. They must also undertake a careful review to ensure that any amendments to a patient’s treatment are appropriate. It is understandable that the practice would wish to review how it actions correspondence from secondary care in order to improve both efficiency and ongoing patient care, but the focus must remain on patient safety. A medicines manager simply undertaking the administrative task of uploading information that has been actioned by a clinical member of staff would be fine, as long as it does not involve any clinical decisions. The practice should regularly review the approach and ensure that systems are in place to monitor the changes. You might also consider asking your local medical committee (LMC) how other practices in the area have approached the same issue.
Q A dental patient has requested to be allowed to use his iPhone to take a photograph of his own radiograph in order to show the image to another practice for an opinion on the potential viability of an implant. Would this be okay or should he be allowed to take the original radiograph?
A The patient is entitled to a copy of his dental records under the Data Protection Act and you are obliged to provide it on request. Original records and radiographs should always be retained. On this basis it would be entirely reasonable to allow the patient to take a photograph of the radiograph. It might be wise to check the smartphone image to ensure it is sufficient for a colleague to assess and, if not, to offer to make arrangements for copies of the records and radiographs to be provided either directly to the patient or to the other dentist. Be aware that any patient-sensitive data sent in electronic form should be encrypted and it might be simpler to print off the records, including X-ray images, and give them to the patient to take to the treating dentist.
TREATING A FAMILY MEMBER
Q We have recently discovered that a healthcare assistant (HCA) at our medical practice has been involved in the treatment of her own 18-year-old son. Can we remove the son from our patient list and institute a policy that immediate family members of practice staff cannot be patients?
A The fact that a patient is related to a staff member would not normally be grounds for removal from the practice list. The HCA’s son is an adult and has the right to be registered with the surgery if he lives within practice boundaries. You should speak to the HCA about ethical guidance on avoiding the treatment of family members and consider referring to such guidance in your practice policy. It would also be advisable to remind the HCA not to access her son’s records uness there is clinical justification. The practice could also implement a policy discouraging family members from registereing, and any current patients this applies to could be asked to consider registering with another practice.
DISPUTED RECORD ENTRY
Q A patient who recently registered at our medical surgery is requesting that notes from the last consultation at her previous practice be removed as they are inaccurate, making reference to potential domestic abuse. Can you please advise how we should respond?
A There is extensive legal and professional guidance in relation to amending patient records. The General Data Protection Regulation (GDPR) permits patients to request amendments to their records. These may relate to the correction of factual errors or redacting sensitive information from notes. In cases where both the doctor and patient agree that the recorded information is factually inaccurate, the record can be amended, but the original information should remain legible and the amendment should be accompanied by an explanation of why there has been an alteration to the records. If there is disagreement over the accuracy of an entry, the patient is entitled to include a statement in the record to that effect. In these circumstances you may wish to offer to include an addendum within the records setting out the patient’s concerns over the entry. It would ultimately fall to the discretion of the patient to contact the previous practice in regard to the disputed entry, but it would be considered good practice for you to ensure the accuracy of the notes and to assist the patient in resolving the matter.
Q An elderly lady who has been a patient at our medical practice for many years has offered to pay for two subscriptions to a local daily print newspaper for the waiting room. Would it be ethical/legal to accept her offer?
A The decision as to whether this gift should be accepted would ultimately lie with the practice and depend on how the gift is perceived by both the patient and healthcare staff. The GMC states in its guidance Good Medical Practice: “You must not ask for or accept – from patients, colleagues or others – any inducement, gift or hospitality that may affect the way you prescribe for, treat or refer patients or commission services for patients.” The practice is also advised to consult GMC guidance on Financial and commercial arrangements and conflicts (paragraphs 6 to 13) which offers advice in relation to gifts and conflicts of interest. 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 approximate value and name of the patient and relevant staff.
CHILD TEST RESULTS
Q Our practice team have been discussing child patient test results and whether these should be sent directly to the parent, to the child or a combination of both. We are based in Scotland – at what age are children considered to have competence and therefore potentially to have their own test results sent directly?
A When considering whether to give young patients (rather than their parents) information about their healthcare, it is important to remember that it is not simply a matter of chronological age. The key is to first assess the child’s capacity to understand the information at hand. The age of consent in the UK is 16, above that age a young person is presumed to have capacity and can consent to treatment in their own right. Below this age a young person might be able to consent to treatment, depending on their maturity and understanding. In Scotland, anyone over 12 years of age is legally presumed to have such capacity. However, the extent of that capacity does of course depend on the individual child. It is not really possible to make a blanket decision that any child over a certain age should receive their own results (results for children under that age should be provided to the parents). It will always depend on the individual situation and the specific child’s capacity. The GMC 0-18 years: guidance for all doctors is a useful resource and includes a section dealing with access to records.