GoodPractice October 2012 · 2016. 1. 19. · issued, ‘Patient confidence and trust in their...

GoodPracticeFor GPs and GPSTs MDU members

Volume 3 Issue 2 October 2012ISSN 2042-9347

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Volume 3 Issue 2 October 2012 GoodPractice EDITORIAL

Medical editor Dr Louise Dale Managing editor Nishma Badiani

This is the sixth issue of Good Practice,published for members of the MDU in the UK. The medico-legal advice in GoodPractice is for general information only.Appropriate professional advice should besought before taking or refraining fromaction based on it.

MDU Services Limited (MDUSL) isauthorised and regulated by the FinancialServices Authority in respect of insurancemediation activities only. MDUSL is an

agent for The Medical Defence UnionLimited (the MDU). The MDU is not aninsurance company. The benefits of membership of the MDU are all discretionary and are subject to theMemorandum and Articles of Association.

Opinions expressed by the authors ofarticles published in Good Practice aretheir own and do not necessarily reflectthe policies of the Medical Defence UnionLimited.

The MDU always seeks to offer attractivebenefits as part of membership and assuch, from time to time, may add,withdraw or amend benefits at itsdiscretion. Visit the-mdu.com for thelatest information of the benefits includedin membership.

MDU Services Limited, registered inEngland 3957086. Registered Office: 230Blackfriars Road, London, SE1 8PJ. ©MDU Services Limited 2012.

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IntroductionWhile the UK has been alightwith Olympic torches and Jubileecelebrations this year, GPs andpractice managers in Englandhave been getting to grips withthe challenge of registering withthe Care Quality Commission(CQC). Our GROUPCAREScheme members can nowbenefit from the online MDUGuide to the CQC and on pages10 and 11, we explain thishelpful tool. On page 12, wealso share lessons learnt fromour dental colleagues since theirregistration with the CQC inApril 2011.

Selective serotonin re-uptakeinhibitors (SSRI) prescribing canunfortunately give rise to anumber of medico-legalconsequences, fromcomplaints, to writing reportsfor the Coroner when a patientcommits suicide. On pages 8and 9, Dr Rachel Sutcliffeprovides some guidance on theprescribing of these drugs.

Domestic abuse leads to anaverage of two women beingmurdered each week. Onpages 14 and 15, Dr YvonneMcCombie examines the GP’spivotal role in identifyingdomestic abuse and theconsequent complex medico-legal issues.

Many of you provide minorsurgical procedures. Dr EllenO’Dell analyses complaints andclaims arising from this work,and advises on reducing therisk of an adverse incident.

Likewise, those of you who fitintra-uterine contraceptivedevices (IUDs) may appreciatethe article by Dr Sally Barnardon pages 18 and 19 that looksat the complications that canarise from the insertion ofIUDs.

Earlier this year, the MDUconducted some research todiscover what readers like mostabout Good Practice and whatsort of articles you would liketo see more of. We havelistened to your views andyou’ll notice some changes inthis issue – more advice linedilemmas, news articles andcase studies.

We hope you like the newcontent.

Dr Louise DaleMedical editor and MDU medico-legal adviser

News in briefGMC welcomes support for revalidation 04Consultation-to-go 04Protecting children and young people 04CPD requirements for revalidation 05Support for doctors and witnesses 05Scottish parliament debates raising concerns 05

In focusDoctors reminded of social media pitfalls 06Difficulty with opioid prescription 07

FeaturesSSRI prescribing: medico-legal pitfalls 08Prepare for CQC with the MDU Guide to CQC 10Disclosing information to the CQC – lessons from dental practice 12AQP – an opportunity for practices 13Recognising and responding to domestic abuse 14

MembershipOximeter promotion 16Your views 16

AnalysisMinor surgery in general practice 20

Advice line dilemmaReturn address raises confidentiality issue 17Intra-uterine contraception 18Estranged father 22

C welcomes supportfor revalidation

Niall Dickson, chief executive of the GMC,welcomed support from the PatientsAssociation for the introduction ofrevalidation for doctors later this year. In aletter to Andrew Lansley, Katherine Murphy(chief executive of the Patients Association)stated that patients and the wider publicagree that doctors should always be able toshow that they are fully up to date and fitto practise and revalidation must remain a priority.

The Patients Association is a healthcarecharity which advocates better access toaccurate and independent information forpatients and the public; equal access tohigh quality healthcare for patients and theright for patients to be involved in allaspects of decision making regarding theirhealthcare.

Ms Murphy stated after her letter wasissued, ‘Patient confidence and trust in theirdoctor is essential. Without it, patient caresuffers immeasurably. Revalidation is a keytool in ensuring that patients can have fullconfidence in their doctor’s abilities andexpertise.’

GoodPractice Volume 3 Issue 2 October 2012

New GMC guidance on protectingchildren and young people will comeinto force in September 2012. Theguidance aims to help doctors protectchildren and young people at risk ofabuse or neglect. The guidance makesclear that all doctors, whether theydeal primarily with adults or children,have this responsibility and adviseswhere they can turn to for support.

The guidance builds on Good MedicalPractice (2006) and includes newsections on sharing information,working in partnership with otheragencies, conducting child protectionexaminations and being a witness in court.

For more information, visithttp://bit.ly/goodpractice25

Pr

It is estimated that patients onlyretain approximately 10% of theinformation given to them from aconsultation. A hospital inEdinburgh is addressing thisproblem by giving patients arecording of the consultation whichthey can take away with them. Therecording is given in situationswhere patients are told of theircancer diagnosis, and where thenext steps are discussed.

The GMC provides guidance todoctors about recordings ofpatients1. The key points of thisadvice are:

• Explain why the recording is needed,and how it may be used and stored.Make a note of the discussion in thepatient’s records.

• If the patient lacks capacity, you willneed to obtain consent fromsomeone with legal authority.

• Children with capacity can provideconsent themselves. Otherwise,obtain consent from someone withparental responsibility. Stoprecording if a child is distressed.

• Keep recordings secure, in the sameway as medical records.

1 Making and using visual and audio recordings ofpatients, GMC 2011

Consultation-to-go

GM otecting children and young people

Volume 3 Issue 2 October 2012 GoodPractice

The GMC has published new guidanceto help doctors understand and achievethe CPD requirements for revalidation.The booklet includes guidance onplanning, implementing and evaluatingCPD credits and how that CPD will beconsidered when the doctor revalidates.

The GMC stresses that the individualdoctor is responsible for identifyingtheir own CPD needs, planning how toaddress those needs and undertakingCPD activities across all aspects of adoctor’s professional practice. Thisincludes clinical and non-clinical dutiessuch as management, research andteaching. Personal development plansshould also be reviewed throughout theyear to ensure they remain relevant.The GMC also emphasises theimportance of reflection; what hasbeen learnt from the CPD activity andwhether the CPD has had any impacton performance or practice.

The CPD activity should be based onthe domains and attributes set out in

the GMC’s Good Medical Practiceframework for appraisal andrevalidation namely:

• knowledge, skills and performance

• safety and quality

• communication, partnership andteamwork

• maintaining trust.

While the majority of the guidance isaimed at the individual doctor, theGMC has included guidance foremployers and organisations.

The MDU has developed a range ofcourses to help doctors achieve CPDcredits across the domains. Visit the-mdu.com/education for moreinformation.

You can read the guidance on theGMC’s website:http://bit.ly/goodpractice26

Scottish parliament debates raising concerns

SThe doctors’ support service is a 12-month pilot scheme offeringemotional support for any doctorundergoing a fitness to practise case.The service is free, completelyindependent of the GMC and run byBMA Doctors for Doctors. Call on 020 7383 6707 or [email protected]

Support is also available for anyonewho reports a doctor to the GMC orwho is asked to give evidence at ahearing. This service is confidential andfree of charge and is run by volunteersfrom Victim Support. A solicitor canmake a referral. Phone 0161 954 1797or email [email protected].

upport for doctorsand witnesses

C

A debate in the Scottish parliament hasonce again highlighted the need forNHS staff to be supported if raisingconcerns. Responding to a questionabout what training and support isprovided in Scotland1, NicolaSturgeon, Scottish healthsecretary, pointed toNHSScotland guidanceon the issue which shesaid encourages aculture of openness inwhich staff may raise anyconcerns as part of their day-to-day practice.

The guidance, Implementing andreviewing whistleblowing arrangementsNHSScotland PIN (partnershipinformation network) policy, aims toensure that staff can safely raiseconcerns ‘where they are witness to

risk, malpractice or wrongdoing thataffects others’.2

MDU members may be reassured bythe guidance from NHSScotland whichencourages Health Boards and

NHSScotland managers to foster aculture of openness, and whichrecommends that local policiesshould make clear that theorganisation takes malpracticeseriously and that those raising

concerns should not suffer anydetriment.

References

1 Scottish parliament – Scotland written answers, 20June 2012

2 Implementing and reviewing whistleblowingarrangements in NHSScotland PIN policy, May 2011http://bit.ly/goodpractice33

PD requirements for revalidation


MDU members have raisedmedico-legal queriesrelating to the use of socialmedia. For example, somemembers had concernsabout maintainingprofessional boundariesafter having beenapproached by patients onsocial networking sites.Other members have beenaccused of underminingpublic confidence in themedical profession throughunprofessional behaviour.Dr James Lucasmedico-legal adviser gives advice on socialmedia best practice for doctors.

pi fall

Doctors

social edi

• Keep your profile private - limit access tofriends only and don't accept requestsfrom patients to become a friend.

• Be professional in your comments,especially about patients or colleagues.

• Be cautious about posting anything thatmay bring the profession into disrepute.

• Be aware that anything you upload onto a social networking site may bedistributed further than you intended.

• The draft guidance is available at:http://bit.ly/goodpractice32

The GMC intends to publish the results ofthe consultation at the end of the year.

The General Medical Council has recently consulted onexplanatory guidance entitled Doctors, use of social mediawhich is one of the publications intended to accompany therevised edition of Good Medical Practice.

The draft guidance makes clear that the standards expectedof doctors do not change because they are communicatingthrough social media rather than face to face or throughother traditional media. Doctors are advised that they mustnot use social media to discuss individual patients or theircare and must follow the guidance in Consent (2008) andConfidentiality (2009) when using social media.

The MDU’s advice about social media can be summarised asfollows:

rem d d o

New guidance issued by NICE aims toimprove pain management for adultpatients receiving palliative care1. The guidance refers to publishedevidence which suggests that painresulting from advanced disease,especially cancer, remains under-treated.

The guidance, which is intendedprimarily for non-specialist healthcareprofessionals, addresses the first-linetreatment of patients assessed asrequiring analgesia at the third levelof the WHO pain ladder. It aims toreduce prescribing errors causingunder-dosing and avoidable pain or

overdosing anddistressing adverseeffects.

Each year, the MDUreceives a number ofrequests for assistancefrom members whohave encounteredmedico-legal issues whenprescribing analgesia inpalliative care. We advisemembers to consider thisnew NICE guidance whenmaking prescribing decisions inthis situation.


Difficulty with

1 Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care ofadults, NICE clinical guideline 140, May 2012 (http://bit.ly/goodpractice28)

Opioid Prescription

Protecting your business

Supportingyour

business

We tailor our corporate solution to fit your businessrather than the other wayaround. Understanding your needs and those of your organisation is at the heart of theway we work. Our solutions continually evolve to meet the everchanging needs of your businessand the healthcare market.

For more information or tojoin the MDU visit:the-mdu.com/corporateor freephone membership helpline 0800 716 376.

MDU Services Limited (MDUSL) is authorised and regulated by the Financial Services Authority in respect of insurance mediation activities only. MDUSL is anagent for The Medical Defence Union Limited (the MDU). The MDU is not an insurance company. The benefits of membership of the MDU are all discretionaryand are subject to the Memorandum and Articles of Association. MDU Services Limited is registered in England 3957086. Registered Office: 230 Blackfriars RoadLondon SE1 8PJ. © MDU Services Limited 2011 OT/014x/0112-b2


A review of MDUcase files over arecent three-yearperiod shows thatprescribing serotoninre-uptake inhibitors(SSRIs) can lead to anumber of medico-legal consequences.Dr Rachel Sutcliffe,MDU medico-legaladviser, reports.

Complaints and inquests can often bedifficult for members. For example, if apatient commits suicide, questions maybe raised about whether this relateddirectly to the SSRI drug rather than tothe underlying mental illness. Members inthis situation are often asked to providestatements for the coroner and to attendinquests to give evidence in person.Bereaved relatives may be critical of thedecision to prescribe an SSRI andquestions are often asked about whetherthe risk of suicidal ideation was discussedwith the patient and whether appropriatemonitoring was in place.

Points of referenceWhen prescribing SSRI medication,doctors are advised to refer to the BritishNational Formulary with regard torecognised side effects and potential druginteractions. You should also refer to NICEguidance1 which recommends thatpatients with depression are advised ofthe potential for increased agitation,anxiety and suicidal ideation in the initialstages of treatment. You should activelycheck for these symptoms and ensurethat the patient knows how to seek helppromptly if necessary2 .

Doctors should also advise patients, andtheir families or carers if appropriate, tobe vigilant for mood changes, negativity,hopelessness and suicidal ideation. Anyconcerns should be highlighted to thedoctor. NICE advises that this isparticularly important during high risk

periods, such as starting or changingtreatment and at times of increasedpersonal stress3.

With regard to the choice ofantidepressant, when initiating treatment,options should be discussed with thepatient including:

• The choice of antidepressant,including any anticipated adverseevents, for example, side effects anddiscontinuation symptoms andpotential interactions withconcomitant medication or physicalhealth problems.

• Their perception of the efficacy andtolerability of any antidepressants theyhave previously taken.4

The guidance also reminds doctors thatSSRIs are associated with an increased riskof bleeding, especially in older people, orin people taking other drugs that mighteffect the gastrointestinal mucosa orinterfere with clotting (such as aspirin or NSAIDs).5

With regard to the suicide cases, acommon criticism was that the doctorhad not adequately warned the patientabout the increased risk of suicidalideation when initiating SSRI treatmentand had not arranged to review thepatient within an appropriate timeframe.

The NICE guidance states that patientsstarted on SSRIs who are not consideredto be at increased risk of suicide, shouldnormally be seen after two weeks andshould be seen regularly thereafter, for


The medico-legal issues giving rise to complaints, claims and coroner’s inquests were:

Reference

1 ‘Depression: The treatment and management ofdepression in adults.’ October 2009, NICE ClinicalGuideline 90, available at www.nice.org.uk.

2 Ibid.Paragraph 1.3.2.23 Ibid.Paragraph 1.3.2.34 Ibid.Paragraph 1.5.2.15 Ibid.Paragraph 1.5.2.26 Ibid.Paragraph 1.5.2.67 Prescription Cost Analysis data for 2010 provided by

the NHS Information Centre, available atwww.ic.nhs.uk

Astudy of requests tothe MDU forassistance relating to

SSRI prescribing revealed thatthe vast majority come fromGPs (83%). Members mostcommonly asked forassistance in responding to acomplaint under the NHScomplaints procedure (52%),while 32% of case filesrelated to coroner’s inquestsand 16% to claims forclinical negligence.

example, at intervals of two to fourweeks in the first three months andthen at longer intervals if the responseis good.

Members should be reassured that it isvery unlikely that they will encountermedico-legal sequelae whenprescribing SSRIs. The MDU opened 23 files over a three-year period, whichmust be considered in context of the231.5 million prescriptions that areissued for SSRIs per annum.7

Members who do encounter anymedico-legal issues as a result of theirprescribing practice are encouraged tocontact the MDU 24-hour freephoneadvisory helpline on 0800 716 646.

The suicide of a patient (32%)

Side effects experienced by patients whilst taking SSRIs (25%)

Inappropriate prescribing of SSRIs due to contraindications, or where drug interactions had occurred

Withdrawal symptoms following discontinuation of SSRIs (11%)

Development of SSRI (serotonin) syndrome whilst taking SSRIs (11%)

(21%)


Prepare for

This autumn, all primary care practices in England will be going through the process of applying for registrationwith the Care Quality Commission (CQC). The MDUhas developed a helpful interactive online guide toassist you with your preparations and beyond*.

After years of anticipation, and atleast one false start, CQCregistration for primary care is

now with us. By the end of 2012, everyqualifying GP practice and primary careorganisation in England must haveapplied for registration. The CQC willthen process the applications and, by 1 April 2013, should have informed allpractices whether their application hasbeen successful and they are CQC-registered.

Completing the application form shouldbe straightforward. The practice has toshow that it is compliant, or workingtowards compliance, with the CQC’s 28essential standards (or ‘outcomes forpatients’). At the time of yourapplication, you may be compliant withsome, but perhaps not all of them. TheCQC says this will not be a bar toregistration providing there is no risk topatient safety.

The devil is in the detail, of course.When the CQC checks a practice’sapplication for registration, they will doso against 16 out of the 28 essentialstandards that are designated ‘core’outcomes – that is, those which relatedirectly to patient safety. The CQC saysyou must have evidence that you meetthese outcomes, or that you can showyou are taking action towardscompliance.

What evidence will youneed?

The CQC has published a list of‘prompts’ against each outcome to helphealthcare providers understand whatthe CQC expects of them1. Primary careorganisations and GP practices areexpected to assess their proceduresagainst the prompts. Where you complywith an outcome, you should be able toproduce evidence to support yourcompliance, or state what actions youare planning to take.

However, the CQC doesn’t specify whatevidence they might expect to see, andit isn’t always easy to see what action

CQC– with the MDU Guide to CQC

For practices inEngland only

detail, with a series of questions to consider.

The guide will:

give you relevant medico-legal andregulatory information and suggestexamples of documents that mayprovide evidence for compliance.

enable you to produce an action plan,from the answers provided in yourreport.

create a report to record your answersand progress, which can be printed ordownloaded, for your records.

save your answers as you progress, tobe completed at your convenience.

‘The MDU guide is designed to take thefear out of applying for CQC registrationfor GPs and practice managers,’ says DrMatthew Lee, MDU professional services

director. ‘It’s simple to use and full ofadditional information to help practices getthe most from their initial application.Once registered, you can use it to maintainyour compliance and to support yourpreparation for periodic CQC inspections.

‘We should stress, of course, that theguide is a support tool. Practices will stillhave to apply for registration through theCQC website. But identifying and collatingthe background information beforehandshould make completing the CQCapplication a smoother and, hopefully,quicker process.’


References

1 The essential standardshttp://bit.ly/goodpractice29

CQC inspectionsThe CQC has said that it will start toinspect primary care organisations andGP practices after April 2013. During aninspection, the inspectors will talk tostaff and patients about the practice.

It is important that staff fullyunderstand, and can articulate, yourpractice procedures and protocols. TheMDU guide gives helpful pointers onwhere staff training would be helpful,and where it may be advisable draw upa written protocol or includeinformation in your staff handbook.

you might need to take if you aren’tcurrently compliant. This is where theMDU Guide to CQC will help.

The MDU Guide to CQC

The MDU Guide to CQC is a step-by-step guide to support practice managersand GP partners in reviewing how theirpractice meets the essential standardsset out by the CQC. The guide is free formembers of GROUPCARE schemesand can be accessed via the My MDUsection on the-mdu.com. The guide hasbeen developed jointly by our medico-legal advisers with extensive experienceof general practice, and Peninsula, whohave expertise in employment andhuman resources. The guide takes youthrough each of the 28 outcomes in

*Available at the-mdu.com for GROUPCARE scheme members only.

How to access the guide

MDU GROUPCARE scheme members can access the MDU Guide to CQC by visitingthe-mdu.com/cqc

If you are not currently a GROUPCARE scheme member but would like to benefitfrom the MDU Guide to CQC, please visit the-mdu.com/groupcare for details on howto set up a scheme, completely free of charge.


The CQC says that from April 2013, itexpects to inspect GP practices everytwo years and will announce their

visit, unless they are responding to aspecific concern. As part of theirinspection, the CQC will talk to staff andpatients and in monitoring compliance theymay gather information from patients. TheMDU has been advising dentists aboutCQC inspections since they becameregistered in April 2011. Drawing on thedental experience, one of the commondilemmas raised about CQC inspections is‘can we disclose confidential patientinformation if it is required as part of theinspection?’

The CQC has the power, under the Healthand Social Care Act 2008, to accessdocuments and information, includingpatient records. However, the CQC’s codeof practice states that it will only obtainpersonal confidential information when it isnecessary to do so.1

The CQC sets out a number of principles toconsider people’s privacy, while ensuring itcan perform its functions effectively.Principle 2 states that ‘To ensure that weare not restricted in our ability to protectand promote the health, safety and welfareof people who use health and social careservices, we will not seek consent where itis necessary to obtain, use or discloseconfidential personal information toperform our regulatory functions.’

However it will try to involve people indecisions to access their information.

Wherever possible and practical, the CQCwill keep individuals informed about how,why and when it uses and discloses theirconfidential information and will only usethe minimum necessary or use anonymisedinformation.

In our experience of helping dentalmembers, it is often possible to seekpatient’s consent for the disclosure of theirinformation to the CQC in connection withits inspection. For example, one dentalpractice was asked to provide a list ofdental patients who had recently receivedtreatment, along with details of thetreatment. This was so that CQC couldapproach the patients to ask them to fill ina questionnaire about their treatmentexperience. The dentist was concernedabout disclosing these details and the DDU(the specialist dental division of the MDU)advised that it may be preferable for thedentist to approach the patients first to askif they would be happy for the dentist topass on their details to the CQC and toanswer questions from them.

It was also suggested that the informationcould be anonymised, for example if thedentist sent out the questionnaires topatients which could then be returneddirect to the CQC, without the patientbeing identified.

References

1 Code of Practice on confidential, personal information,CQC, December 2010 http://bit.ly/goodpractice30

2 GMC, Confidentiality (2009), paragraph 19.

Disclosinginformation to

the CQC – lessonsfrom dental

practice

The CQC has said that it will start to inspect primary care organisationsand GP practices after April 2013. Dr Sally Old investigates the medico-legal issues around disclosing information to the CQC.

GPs have an ethical duty to ensure patientsare informed about how their informationwill be used. The GMC states that whereverpracticable you should inform patients aboutdisclosures required by bodies that havestatutory powers, such as CQC, unless thatwould undermine the purpose, even if thepatient’s consent is not required.2

With this in mind, once registered with theCQC, practices may wish to review theirpractice leaflets, information on theirwebsites, and, to ensure they make it clearthat in some cases they may need to discloseidentifiable information occasionally as partof the CQC inspection process but this isusually done with consent and, whereverpossible, they will provide anonymisedinformation so that individual patients arenot identified.


Under the ‘any qualified provider’(AQP) model, any provider,including a GP, who is qualified

and able to provide a specific clinicalservice that meets the required standards,can be listed as a possible provider. Thereis an opportunity for practices to provideeither the service itself, or to rent space inthe practice for specialist areas such asMSK and ENT services, adult hearingservices, diagnostic tests, podiatry, venousleg ulcer and wound healing or primarycare psychological therapies.

However, no provider will have aguarantee of any volume of activity aspatients will choose the provider on theAQP list they wish to visit. The firstpractices to be accredited, or rent spacein their practices for others to use, arelikely to see the benefits quickly. As wellas patients from the whole CCG area,

your own patients can book the servicestoo (through normal ‘Choose and Book’arrangements).

A provider will need to be jointly licensedby the CQC and Monitor in order to beon an AQP list.

The Department of Health states thatAQP will enable patients to ‘choose anyqualified provider where this will result inbetter care’. The principle is that choice ofprovider will enable individual patients toreceive the best service for them, while asystem of several providers will, throughcompetition, improve overall standards.

Terms and conditions for each AQPcontract will include local referralthresholds and patient protocols. Theprice will be determined by national tariff(if present), or by local agreement if thetariff is absent. Patients will choose

practices based on how attractive yourpractice is, in terms of how convenientyour reception arrangements are and thegeneral patient experience during theirAQP consultation. Providers will be listedin a CCG managed directory so allproviders can be viewed.

Over time, AQP will become a majorresource of commissioning care alongsidemore conventional forms of tenderingand other services being provided by GPpractices such as directed enhancedservices.

An opportunityfor practicesby Chris Acton, Director ofThe Primary Care Partnership

AQP

The Primary Care Partnership Ltdis an independant consultancyspecialising in advising generalpractices.

GPs are encouraged to look closely at indemnity arrangements before taking up contracts for extendedservices and contact the MDU membership department about cover if intending to provide these under a new

or existing contract. If you are planning to set up a company to provide clinical services under the AQPprogramme don’t forget to contact [email protected] for guidance on indemnity matters.

The views expressed in this article are the author’s own.


Recognising andResponding todomestic abuse

Domestic abuse affects an estimated one in fourwomen and one and six men1. It accounts for

16% of all violent crime in England and Wales2

and leads to the murder of two women a weekand 30 men a year. Yet it is the violent crime least

likely to be reported to the police. GPs play apivotal role in identifying and supporting victimsof domestic abuse, says Dr Yvonne McCombie,

MDU medico-legal adviser.

hen a patient who may be subjectto domestic abuse presents, a

number of complex dilemmas arise forthe general practitioner. Is abuseactually taking place? Is there animmediate risk to the patient and her orhis children and if so, what is the extentof the risk? How can the patient’sconfidentiality3 be maintained? Howcan the GP work effectively with thepatient to ensure appropriate furtherreferral?

One thing all victims, children andperpetrators of domestic violence havein common is that they have a GP. GPsare therefore in a crucial position toassist victims through identifying abuseand providing specialist supportservices.

In recent guidance to GPs4 the RCGPhighlighted:

• The role of practice managers inestablishing strong relationshipswith local domestic abuse services.

• Establishing a designated person,trained in the specialist assessmentof victims.

• Setting up a domestic abuse carepathway within the primaryhealthcare team, and theimportance of the whole teamunderstanding the process foridentifying abuse, responding todisclosure, risk assessment, referraland sharing information.

Consider the confidentiality of patientsand that information will be shared onlywith the consent of the patients,subject to practice policy on child

protection and adult safeguarding.Additionally, GPs should follow theGMC confidentiality guidance3.

Training requirements

The whole team, clinical and non-clinical, should be trained in recognisingthe signs of domestic abuse, makingappropriate enquiries, respectingconfidentiality and the process forresponding.

The GP’s role includes

• considering the possibility of abuseand asking the question

• emphasising and protecting thepatient’s confidentiality

• documenting clearly informationand injuries presented

W

The medico-legal adviserdiscussed with the GP theneed to sensitively ‘ask thequestion’ during theconsultation as to whetherthe bruises were the result ofdomestic abuse. The GP wasalso advised to ascertainwhether there was anyimmediate serious risk to thepatient herself, or to anyother individuals or children.Her response and anyfindings should be carefullydocumented in the records.

He would need to clarifywith the designated personwithin the practice theprocedures and protocols tofollow in the case of apatient suffering fromdomestic abuse.

Finally, he was advised toreassure the patient of herrights to confidentiality andseek her consent for anydisclosures within thepractice protocol. If thepatient did not consent to

disclosure, he should explainthe circumstance in which hemight be justified indisclosing informationwithout consent, namelywhere there is a risk ofserious harm to an individualor to children.

The adviser invited themember to call back todiscuss these circumstancesfurther if required.

After further assessment ofthe patient, the GP did notfeel there was anyimmediate danger to thepatient and she had no otherchildren who could havebeen at risk. The patient did,however, disclose that shehad been subject to violentabuse by her partner and theGP advised her of theprocedures that wereavailable to make a referralto specialist agencies to

provide her withongoing support.


A 30-year old female patient presented to her GPfollowing a fall and complaining of abdominalpain. The patient was 16 weeks pregnant.

Examination confirmed that the pregnancy wasproceeding well but the GP noticed some bruising tothe patients abdomen and forearms. Looking at therecords, the patient had previously attended followinga fall downstairs. Despite the GP’s concern about thebruises, the patient was reluctant to discuss themfurther. He did, however, suggest that the patientattended for a further review, which she agreed to.The GP contacted the MDU for advice as to his dutiesin identifying domestic abuse and protecting hispatient’s confidentiality.

• assessing the present situation and any immediatesafety issues.

It is also important for GPs to have a clear pathway toallow ongoing review and follow up in patientssuffering from domestic abuse.

MDU experience

An analysis of 29 cases reported to the MDU involvingdomestic abuse in a recent two-year period showed:

• 25 involved GP members seeking advice ondisclosure of records to patients in connectionwith court cases arising from domestic abuse, andon confidentiality and disclosure to appropriateagencies

• four related to other specialties who had beenasked to provide a report for the police as part ofdomestic abuse investigations.

During the same period, we also received 267 calls tothe advisory helpline from doctors seeking advice, inparticular on the confidentiality aspects of providingcare and support to victims of domestic abuse.

MDU advice

The MDU has the following advice for GPs inmanaging these complex cases.

• Be aware of current guidance on the identificationand management of patients presenting withapparent signs of domestic abuse.

• Ensure the practice has a clear protocol in place.

• If domestic abuse is suspected, it is important toask the question and to document all informationand clinical examination very carefully.

• There should be a clear set of procedures to followin those cases where immediate risk to the patientor children is identified.

• Doctors should be mindful of their duties ofconfidentiality to their patients and to stress theimportance of this and seek consent for alldisclosures where possible.

In circumstances where there is a significant risk ofserious harm, advice should be sought regardingjustification of disclosures in the public interest.

GPs should follow the GMC’s guidance inConfidentiality (2009) and Protecting children andyoung people (2012).

The issue of domestic abuse and its identification andmanagement in general practice is complex andmembers of the MDU who have concerns aboutmedico-legal issues arising from the treatment ofpatients suffering domestic abuse can discuss thesewith one of our team of medico-legal advisers. Pleasecall our 24-hour freephone helpline on 0800 716 646.

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References

1 Living without abuse website (lwa.org.uk)2 Crime in England and Wales 04/05 Report3 GMC: Confidentiality (2009)4 RCGP press release 24 May 2012

Yourviews


We would like to include youropinions and comments on the featured

articles in Good Practice, and welcome yourhumorous anecdotes about incidents that happenwithin your practice.*

Send your comments or stories to the-mdu.com/feedback, or email

[email protected].

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*We may print your stories and comments. Please note that any comments or storiesthat you send must not breach patient confidentility.

This easy-to-use module is an introduction tomedical ethics and law. It guides you through ethicaldilemmas often experienced in day-to-day practice.

Medical Ethics and Law

© MDU Services Limited 2012 GN/100x/0812 Visit the-mdu.com and click on Online CPD

- Expertly authored by MDU medico-legal advisers.- Can be completed at your own pace.- Interactive module, accessible at any time,

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5 points


You are right to be concerned as even thefact that a patient is registered at a practiceis confidential medical information and

should not be disclosed without the consent ofthe patient. However, having the practice’saddress on an envelope may not equate to therecipient being registered at the practice. Thepractice may, for example, be writing to a supplierof goods or services.

It could also be argued that having a returnaddress on the practice correspondence is in thepublic interest, because if the mail is undeliveredor returned, you can take steps to contact thepatient in some other way. If, however, youbelieve circumstances exist which will result inyour address on the envelope identifying therecipient as a patient, you may wish to considertaking alternative measures to omit your identity,such as using a PO Box number.

GMC guidance on confidentiality recommendsthat patients are made aware of how informationabout them will be used. In line with this, theMDU’s advice is to inform patients of your practicepolicy for communicating with them, explainingthat it may be possible to identify correspondencesent by post because it will display a returnaddress label. You may decide to tell patientsthrough a notice in the waiting room, or a noteon prescriptions, for example. If a patient objectsto receiving correspondence by post, you mayneed to remove any identifying labels, or findanother way of communicating with that patient.

‘With the rise in postal prices our practice has invested in a franking machineto save costs. It automatically putsour return address on all post. Weare concerned that this might bea breach of confidentiality as itwill be clear to anyone who seesthe envelope that the person wehave written to is a patient.Should we be worried?’ Dr Naeem Nazem, medico-legal adviser,answers this advice line call.

raisesconfidentiality

issue


Intra-uterinecontraception

Case one

A GP contacted the MDU advice line to discuss a letter thatshe had received from a firm of solicitors acting for apatient who was alleging negligence by the doctor inrespect of an intra-uterine contraceptive device (IUD)insertion. The doctor had inserted the coil in themultiparous patient at her post-natal visit. The insertionhad been easy but the GP had been concerned that theuterus might have been perforated and subsequentinvestigation had found the IUD to be outside the uterus.Fortunately it was easily removed at laparotomy and thepatient made a complete recovery.

Case two

Outcome

A GP attempted to fit an IUD into a multiparouswoman but had to discontinue the procedure owingto pain. The GP had arranged for the patient to beseen by a gynaecologist who fitted the device. Allseemed well and the GP was astonished to receive aletter of complaint from the GMC. The patient hadalleged that the GP had continued with the insertionafter she had complained of pain and she also allegedthat the treatment room had not been clean.

The MDU adviser assisted the GP in writing a responseto the GMC which explained that a degree ofdiscomfort was not unusual but that the GP haddiscontinued the procedure when the patient had firstasked him to. The GP apologised for any distress thathad been caused. A statement was also provided by thepractice nurse who had assisted at the procedure. ThePCT were aware of the complaint and held a meetingwith the GP at the surgery. They were satisfied with theexplanation and also with the infection controlprocedures in place at the surgery. The GMC complaintwas closed with no adverse outcome.

Complications with inserting IUDscan result in correction proceduresor even perforation of the uterus. Dr Sally Barnard outlines two casesthat gave rise to complaints.

OutcomeIn this case, the GP had warned the patient about the riskof perforation and this was clearly documented in themedical records. The MDU claims handler assisted thedoctor to write a response to the solicitors and the claimwas discontinued.

IUDs are the contraceptive of choice for many women inthe UK, and when used correctly can provide effectiveprotection against pregnancy in over 99% of cases.However, doctors who insert IUDs, as well as those whoprovide care for women with IUDs in situ, must bemindful of the complications that can arise from their use.


The MDU has reviewed its claims andcomplaints files relating to IUDs over thelast ten years. The review showed 98

cases in the ten-year period. Perforation ofthe uterus after insertion was the mostcommon reason for members to seekassistance with a claim or complaint in thisarea, followed by failure to remove thedevice. Although the number of casesnotified to the MDU in this area is small, thecomplications that have led to complaints andclaims can be serious, so there is no room forcomplacency. This is particularly importantgiven that the top two reasons for complaintsand claims relate to the carrying out of theprocedure itself.

The main reasons for MDUmembers seeking assistance withclaims and complaints in this areawas perforation of the uterus(40%). Perhaps surprisingly, thenext common reason relates to afailure to remove the device,16%of cases. In 12% of cases, thewoman had become pregnantfollowing insertion of the coil andalleged that she had not beenwarned that the coil had a failurerate. In a further 9% of cases wasalleged that the doctor had failedto ensure that the woman was notpregnant at the time of insertionof the device.

It is essential that doctors insertingIUDs ensure that they areappropriately trained in theprocedure and regularly updatetheir skills in this area. Suitabletraining and experience areimportant. The GMC says inparagraph 3(a) of Good MedicalPractice (2006) that doctors ‘mustrecognise and work within thelimits of their competence’.

Paragraph 12 of the same GMCguidance states that ‘you mustkeep your knowledge and skills upto date throughout your workinglife. You should be familiar withrelevant guidelines anddevelopments that affect yourwork. You should regularly takepart in educational activities thatmaintain and further develop yourcompetence and performance’.

Doctors should always checkwhether there is a possibility that apatient could be pregnant beforefitting an IUD device. If there is anydoubt, a pregnancy test should becarried out.

The date of the patient’s lastmenstrual period should alsobe ascertained and recordedin the medical notes.

Doctors should make sure thatmedical records are clear anddetailed, and contain information

about when the device should beremoved, as well as any problemsthe patient may experience whilethe device is in situ. The practicemight wish to consider having aregister of patients with an intra-uterine device and issue reminderswhen these are nearing theirremoval date. Alternatively therecommended date of removalshould be recorded in the medicalrecords and patients remindedopportunistically, although this isdependent on the patientattending the surgery.

When fitting a new IUD, doctorsshould make sure that anyprevious devices are removed priorto inserting the new one.

Women should be asked routinelyabout any past history of sexuallytransmitted infections. Womenidentified as being at high risk, orthose who are currentlysymptomatic should be screened inorder to exclude infection prior toinsertion of the device.

With the advent of revalidation,doctors might also wish to ensurethat some of their CPD activity forthe year relates to intra-uterinecontraception and that they havereflected on both their clinicalactivity and their CPD.

Complications relating to intra-uterine contraceptive devices areuncommon but if they do arisethen the members should contactthe MDU at an early stage todiscuss how to answer thecomplaint or claim.


Reasons for claims and complaints

The primary concerns raised were:

Post-operative complications 42 cases

Delay in diagnosis/referral 13 cases

Unsuccessful outcome 9 cases

Scarring 9 cases

Consent 3 cases

Burns 3 cases

Accidental injuries 3 cases

Wrong site 2 cases

Other 29 cases

The most common type of case involved post-operative complications (37%), includinginfections, bleeding and pain. Of course, such problems are a risk in any invasive procedurebut in some cases, better monitoring may have enabled the GP to spot problems earlier.

Delays in diagnosis or referral accounted for about 15% of cases, predominantly involvingdermatological procedures. In six of these, a malignant melanoma was initially missed orthought to be clinically benign. Cases in which patients complained of an unsuccessfuloutcome most commonly involved a failed vasectomy, while scarring was often a factor indermatology cases.

Failure to obtain valid consent was the principal allegation in three claims but was also afactor in a further six claims where it was alleged that the GP had not properly warned thepatient of the risk of post-operative complications or scarring. Of course, this is an

MDU medico-legal adviserDr Ellen O’Dell assesses the

reasons for claims andcomplaints following minor

surgery and offers riskmanagement advice.

From treating in-growing toenails toremoving skin lesions, many GPpractices provide a range of minor

surgical procedures. In most cases, thisoffers patients a quicker and moreconvenient alternative to seeing aspecialist but occasionally problems canarise which may lead to a complaint orclaim.

The MDU reviewed 112 cases notifiedby GP members in a recent four-yearperiod, of which 69 were claims. Whileabout half these claims are still active,18 were settled for a total of just over£410,000 plus legal costs. Thecompensation awarded ranged from justover £500 for a diathermy burn during acauterisation procedure, to over£220,000 to a man who was left in painfollowing a vasectomy. A further 17cases were discontinued or closedbecause they were outside the timelimit. The remaining files were incidentswith the potential to become claims,including 34 complaints.

Dermatology procedures featured mostcommonly (43 cases) but other casesinvolved vasectomies (21), circumcision(10) and treating in-growing toenails (5).


A patient visited her GP requesting the removal of alesion on her leg. The GP diagnosed a wart and laterremoved it during his minor surgery clinic usingcryotherapy.

At follow-up, the lesion had returned and this timethe GP decided that a shave excision be carried out soit could be sent for histological examination.However, the patient’s appointment was with adifferent GP who was unable to access her recordsduring the appointment because of a computerfailure. The GP asked the patient what she washaving done and she explained she was there to havea wart removed. Unaware that she had already hadthe procedure once, the GP removed the lesion usingcryotherapy.

The patient failed to attend for a review and it wasonly when she returned to see the first GP six monthslater complaining that the lesion had returned againthat he discovered what had happened. He made anurgent referral for the patient and a diagnosis of basalcell carcinoma was made. Fortunately, she respondedwell to treatment but later made a complaint aboutthe practice’s failure to treat her appropriately whichhad led to a delay in diagnosing her condition.

The GP practice held an adverse event meeting todetermine what had gone wrong and how it mighthave been prevented. It was felt that the second GPshould have double-checked the records when thecomputer system was up and running. However, itwas also recognised that the patient’s missed reviewappointment might have been picked up if thepractice had had a tracker system in place and thatthis should be implemented as a matter of urgency.

The complaints manager then wrote to the patientapologising for what had happened and explainingwhat action would be taken. The patient did notpursue the complaint.

This is a fictional case compiled from actual casesin the MDU files.

important part of clinical practice but in the MDU’s experience suchallegations are not uncommon in claims and highlight the importanceof the consent discussion and its careful documentation.

The remaining files featured problems such as burns, accidental injuriessuch as falls from the operating table and two mole excision cases wherethe procedure was allegedly performed on the wrong site.

Reducing the risk

The following tips, based on our analysis, could help GP practicesreduce the risk of an adverse incident:

• Follow the latest relevant national guidance. For example, theRevised guidance and competences for the provision of servicesusing GPs with Special Interests (GPwSIs): dermatology and skinsurgery1 can be downloaded from the NHS Primary CareCommissioning website.

• Ensure you are appropriately trained, qualified and experiencedand keep your surgical skills up-to-date. Your PCT may requirespecific accreditation for GPs who carry out minor surgery.

• Consider whether the size and site of each condition makes itappropriate for treatment in general practice, or if a referral isneeded.

• Obtain valid consent, warning the patient about the risks,potential benefits and alternatives to the procedure and thepossibility of an unsuccessful outcome. This discussion should benoted in the records.

• Be aware of and follow infection control guidelines.

• Provide information about follow-up arrangements and post-operative care. Tell patients who to contact if any complicationsarise.

• Send excised lesions for histological examination and record thedetails of specimens sent, results received and follow-up arranged.

• Follow the manufacturer’s guidance on equipment use andmaintenance.

• Carry out regular audits of minor surgery, including clinicaloutcomes.

• If you delegate tasks, ensure that the person to whom youdelegate is trained and competent to do the work.

• If something goes wrong, explain to the patient what hashappened and the steps you now need to take. Be prepared toapologise.

If you perform surgical procedures as part of your general practice work,please contact the MDU membership department to let us know whichprocedures you perform and what experience, training and qualificationsyou have to do each procedure. There is no need to contact us aboutprocedures you have already told us about.

You do not need to tell us if you carry out the following:-excision of ‘lumps and bumps’ where malignancy is not suspected(sebaceous cysts, small lipomas, etc), drainage/aspiration of cysts andbursae, intra-auricular injections, cryotherapy/diathermy/uretagge (e.g.warts, verrucae, molluscum contagiosum), ingrowing toenails (removal ofnail only - not nailbed).

1 Revised guidance and competences for the provision of services using GPs with Special Interests(GPwSIs): Dermatology and skin surgery, NHS Primary Care Commissioning, April 2011http://bit.ly/goodpractice31

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Estrangedfather

The advice

The outcome

It is easy to become embroiled in disputes between the parents ofyoung patients. You should always bear in mind that the child is thepatient, and act in the child’s best interests.

• Parents will normally continue to have parental responsibilityonce divorced and are equally entitled to request access to theirchild’s records.

• Appropriate parts of the records may be disclosed if this in thechild’s best interests where the child does not have capacity toconsent, or does have capacity and provides consent.

• If the child has capacity but declines consent to disclosure, thisshould usually be respected.

• You must comply with a court order ordering disclosure.

A GP received a letter fromsolicitors acting on behalf ofthe father of a 13-year oldpatient with cystic fibrosis. Theletter requested disclosure ofthe child’s medical records.The father was in the processof divorcing the patient’smother who didn’t want thefather to contact hisdaughter, on the groundsthat he was unable to carefor the child properly as hedid not fully understand thegirl’s condition.

The GP believed the patienthad a mature understandingof her condition, and that itwould be helpful for thefather to see the records. She rang the MDU for advice.

The MDU adviser explained that even though the parents weredivorcing, the father would still have parental responsibility for hisdaughter. He would have the same rights as the mother to requestaccess to the child’s medical records.

However, there is no absolute right for parental access to records.Rather, this would be determined by what is in the best interests ofthe child. If the child has capacity, she can usually allow or preventaccess to his records by others, including her parents.

In Scotland, anyone aged 12 or over is legally presumed to have suchcapacity, while in England the age is 16 years. However, capacitydepends more on a patient’s ability to understand and weigh upoptions than on age.

The adviser suggested that the GP might see the patient on her own,to assess her capacity and to explore her views about sharinginformation with her father. All discussions should be fullydocumented in the child’s records.

The GP discussed the situation with the patient, and from thatconversation she thought the girl did have capacity to understand,retain, and weigh the pros and cons of sharing her medical recordswith her father and did not feel the mother was influencing thatdecision. However, the patient declined consent to release herrecords to her father. Although the GP had encouraged the patientto involve her father in her care, she did not feel that it would be inthe patient’s best interests to disclose the records without herconsent. For example, the father did not need the records to enablehim to protect the patient from the risk of serious harm.

The MDU adviser helped the member to respond to the solicitors,saying that she had assessed the patient to have capacity to consentto the father’s request and as the patient had declined to giveconsent, the member was unable to disclose the records. Thesolicitors could apply to the court to determine the issue, if theywished, and if a court order was made for disclosure, the GP wouldcomply with this.

Points to remember

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