healthy workforce: Creating a Managing change

Volume 8 Issue 2 October 2012
ISSN 1749-3595
Creating a
healthy
workforce:
Managing change
Supporting your business
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is at the heart of the way we work. Our solutions continually evolve to meet
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Protecting your business
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respect of insurance mediation activities only. MDUSL is an agent for The Medical Defence Union
Limited (the MDU). The MDU is not an insurance company. The benefits of membership of the
MDU are all discretionary and are subject to the Memorandum and Articles of Association. MDU
Services Limited is registered in England 3957086. Registered Office: 230 Blackfriars Road
London SE1 8PJ. © MDU Services Limited 2012.
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contents
news in brief
4 Too old to practise?
4 Data protection fines
4 Treating overseas patients
in focus
Registration check-up
Consultation-to-go
Bulk email dangers
AQP – an opportunity
for practices
features
7 Dealing with sickness
absence
8 Prepare for CQC with
The MDU Guide to CQC
10Creating a healthy workforce:
managing change
12 Managing medical records
Introduction
Welcome to the October issue of inpractice, the journal
exclusively for MDU practice manager members.
This issue focuses on change and the impact it can have on staff
in your practice. As well as potentially affecting the day to day
running of your practice, change can also be very unsettling for
some employees. The article on managing change (pages 10 and
11) and dealing with sickness absence (page 7) in the features
section aims to help you mitigate the negative effects as you go
through the process of change.
As part of our commitment to support our primary care members,
we have launched The MDU Guide to CQC. The CQC will
regulate practices in England, who must apply for registration
with the Care Quality Commission before the end of 2012 (pages
8 and 9).
Earlier this year, the MDU conducted some research to discover
what readers like most about inpractice and what sort of articles
they would like to see more of. We have listened to your views
and you’ll notice some changes in this issue - more feature
articles, a condensed membership news section and more hints
and advice on employment law.
We hope you like the new content.
Dr Beverley Ward
Medical editor and MDU medico-legal adviser
practice dilemma
14 Prescribing errors
membership
15 End of life seminar
15 Nursing duties: update
your records
15 Oximeter promotion
Medical editor
Dr Beverley Ward
This is the thirteenth issue of inpractice,
published for members of the MDU in the
UK. The medico-legal advice in inpractice is
for general information only. Appropriate
professional advice should be sought before
taking or refraining from action based on it.
Opinions expressed by the authors of
articles published in inpractice are their own
and do not necessarily reflect the policies of
the Medical Defence Union Limited.
Your views
We would like to include your opinions and comments on
the featured articles in Inpractice, and welcome your
humorous anecdotes about incidents that happen within
your practice. We may print your stories and comments.
Please note that any anecdotes you send in must not breach
patient confidentiality.
Send your comments or stories to the-mdu.com/
feedback, or email [email protected]
Managing editor
Nishma Badiani
The MDU always seeks to offer attractive
benefits as part of membership and as such,
from time to time, may add, withdraw or
amend benefits at its discretion. Visit themdu.com for the latest information of the
benefits included in membership.
MDU Services Limited (MDUSL) is
authorised and regulated by the Financial
Services Authority in respect of insurance
mediation activities only. MDUSL is an
agent for The Medical Defence Union
Limited (the MDU). The MDU is not
an insurance company. The benefits of
membership of the MDU are all
discretionary and are subject to the
Memorandum and Articles of Association.
MDU Services Limited, registered in
England 3957086. Registered Office:
230 Blackfriars Road, London, SE1 8PJ.
We welcome your feedback. If you have
any queries or comments, or would like to
request more information on a particular
topic, please write to:
Feedback
5
5
5
6
Editorial
Marketing Department
MDUSL
230 Blackfriars Road, London, SE1 8PJ
or post on our website at
the-mdu.com/feedback
or email [email protected]
3
Newsinbrief
Too old
to practise?
Practices may set a mandatory
retirement age for GP partners
but must be able to justify doing
so, following a supreme court
judgment in April 2012.
That case was brought by a
solicitor who claimed age
discrimination because the terms
of his partnership agreement
required him to retire at 65.
His firm argued that the
mandatory retirement age
gave associates an opportunity
of partnership within a
reasonable timeframe; that it
enabled workforce planning;
and limited the need to expel
underperforming partners.
While the court accepted that
the firm’s aims were legitimate
and dismissed the solicitor’s
appeal, the case was referred
back to an employment tribunal
to decide whether the firm’s
stipulated retirement age of 65
was appropriate and necessary.
Data protection
fines
Practices are advised to seek
expert legal advice before
including a retirement age in
partnership agreements.
Data controllers in practices should
check they have robust safeguards
to protect confidential patient
information after a number of health
organisations were fined for serious
breaches of the Data Protection Act.
The judgment warned: ’All
businesses will now have to give
careful consideration to what, if
any, mandatory retirement rules
can be justified1.’
Reference
1
Seldon v Clarkson Wright and Jakes,
Supreme Court Judgment, 25 April 2012,
[2012] UKSC 16.
http://bit.ly/inpractice08
Treating overseas
patients in the UK
Updated guidance from the
Department of Health clarifies the
responsibilities of GP practices that
care for overseas visitors. It states:
• GPs have a duty to provide,
free of charge, emergency or
immediate necessary treatment,
to anyone who requires it, and to
refer patients on the basis of
clinical need.
4
• Having an NHS number, or
being registered with a GP
does not automatically entitle
anyone to free hospital care,
and whilst GPs need to be
aware of this so that they can
inform their patients
appropriately, it is the NHS
body’s responsibility (not the
GP’s) to establish entitlement
to free NHS care.
• Charges only apply for hospital
treatment, or treatment
provided in the community
by hospital employed or
directed staff.
The full guidance can be reviewed
at: Implementing the Overseas Visitors
Hospital Charging Regulations 2011 full
guidance. http://bit.ly/inpractice9
In May, the Information
Commissioner’s Office (ICO)
announced a £90,000 fine against
Central London Community
Healthcare NHS Trust after patient
lists containing sensitive personal
data were faxed to the wrong
recipient2.
This followed news that the Aneurin
Bevan Health Board in Wales had
become the first NHS organisation
to receive a fine (£70,000) when a
confidential report was sent to the
wrong person3. Inadequate staff
training was found to be a root
factor in both cases. In June,
Brighton and Sussex University
Hospitals NHS Trust were fined
£325,000 after patient data was
found on hard drives sold on an
internet auction site4.
The MDU has produced data
protection advice for members
which is available on our website,
the-mdu.com.
References
2
3
4
London NHS Trust fined £90,000 for serious
data breach, ICO, 21 May 2012.
http://bit.ly/inpractice10
CO issues first penalty to the NHS following
serious data breach, ICO, 30 April 2012.
http://bit.ly/inpractice11
NHS Trust fined £325,000 following data
breach affecting thousands of patients
and staff, ICO, 1 June 2012.
http://bit.ly/inpractice12
Infocus
Registration
check-up
Primary care practices must ensure
nurses they employ are registered
with the Nursing and Midwifery
Council (NMC). The CQC may also
ask to see evidence of nurses'
registration as part of the inspection
process to begin next year. This is
particularly important in the light
of a news report last November
which estimated there could be 180
unregistered ‘nurses’ working
illegally in GP practices throughout
the UK1.
Practice managers can confirm a
nurse’s registration status through
the NMC’s employer confirmation
service. Further information is
available at www.nmc-uk.org/
Employers-and-managers.
References
1
Fraudulent or rogue nurses employed by up
to 200 practices, Pulse, 9 November 2011.
http://bit.ly/inpractice13
Consultation-to-go
Patients only retain an estimated
10% of the information they are
given during a medical consultation.
A hospital in Edinburgh is
addressing this problem by offering
selected patients a recording of the
consultation which they can take
away with them. The recording is
given where patients are told of their
prostate cancer diagnosis, and where
the next steps are discussed. It is
hoped that this might remind
patients of the sometimes complex
information they are told during this
distressing time2.
GMC guidance to doctors about
recordings of patient consultations3
advises:
• Explain why the recording is
needed, and how it may be used
and stored. Make a note of the
discussion in the patient’s records.
• If the patient lacks capacity, you
will need to obtain consent from
someone with legal authority.
• Children with capacity can
provide consent themselves.
Bulk email dangers
Breaches of confidentiality can
occur when sending out
emails to multiple patients.
If emails are sent to several
addresses using the ‘To’ or
‘CC’ fields, the recipient of
the email will be able to see
the addresses of the other
patients. However, if the
‘BCC’ field is used instead,
recipients won’t be able to see
the other addresses.
Otherwise, obtain authority
from someone with parental
responsibility. Stop recording
if a child is distressed.
• Keep recordings secure, in the
same way as medical records.
References
2
3
NHS Lothian offers ‘bad news’ recordings
to prostate cancer patients.
http://bit.ly/inpractice14
GMC, Making and using visual and audio
recordings of patients (2011).
The MDU’s advice is:
• Use your own email address in
the ‘To’ field and use ‘BCC’ for
all recipients.
• Ensure that you have prior
consent from the patient to
contact them by email.
• Ensure that patients are able
to opt out at any time.
If a mistake is made in a bulk email,
ensure the affected patients are
informed immediately, and notify
the Information Commissioners
Office (ICO).
Further information on the ICO
can be found at ico.gov.uk.
5
Membership
Infocus
AQP
– An opportunity
for practices
By Chris Acton, Director of the
Primary Care Partnership.
U
nder the ‘any qualified
provider (AQP)’ model, any
provider, including a GP,
who is qualified and able to provide
a specific clinical service that meets
the required standards, can be listed
as a possible provider. There is an
opportunity for practices to provide
either the service itself, or to rent
space in the practice for specialist
areas such as MSK and ENT services,
adult hearing services, diagnostic
tests, podiatry, venous leg ulcer
and wound healing or primary care
psychological therapies.
However, no provider will have a
guarantee of any volume of activity
as patients will choose the provider
on the AQP list they wish to visit.
The first practices to be accredited,
or rent space in their practices for
others to use, are likely to see the
benefits quickly. As well as patients
from the whole CCG area, your own
patients can book the services too
(through normal ‘Choose and Book’
arrangements).
A provider will need to be jointly
licensed by the CQC and Monitor
in order to be on an AQP list.
The Department of Health states
that AQP will enable patients to
‘choose any qualified provider
where this will result in better care’.
The principle is that choice of
provider will enable individual
patients to receive the best service
for them, while a system of several
providers will, through competition,
improve overall standards.
Terms and conditions for each AQP
contract will include local referral
thresholds and patient protocols.
The price will be determined by
national tariff (if present), or
by local agreement if the tariff
is absent. Patients will choose
practices based on how attractive
your practice is, in terms of how
convenient your reception
arrangements are and the general
patient experience during their AQP
consultation. Providers will be listed
in a CCG managed directory so all
providers can be viewed.
Over time, AQP will become a major
resource of commissioning care
alongside more conventional forms
of tendering and other services
being provided by GP practices such
as directed enhanced services.
The Primary Care Partnership Ltd
is an independent consultancy
firm specialising in advising
general practices.
The views expressed in this article are the author’s own.
GPs are encouraged to look closely at indemnity arrangements prior to taking up contracts for extended services
and contact the 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 AQP programme don’t forget to contact
[email protected] for guidance on indemnity matters.
6
Feature
Dealing with
sickness
absence
On average, each employee has
5.5 days of sickness absence per
year 1. Multiply that by the
number of employees in your
practice and you could have as
much as a couple of months’
worth of sickness absence in one
year. Nicola Mullineux, research
co-ordinator at Peninsula
Business Services looks into the
best ways of dealing with
sickness absence.
T
he impact of sickness absence
on your practice is considerable.
You may need to organise
extra cover and redistribute tasks
among remaining staff – possibly at
short notice. There is also additional
administration involved, such as
calculating sick pay. Sickness absence
is enhanced in a medical practice,
where exposure to health risks is
significantly higher. It is impossible
to eliminate the time you spend on
administration, but it may be
possible to reduce it by implementing
procedures that target suspected
abuses of sickness absence. Even
genuine cases of absence may be
reduced by careful management.
Sickness absence
record keeping
Keeping a record of time off that
staff credit to sickness is crucial
for monitoring sickness absence.
By doing this, you are also making a
statement to your staff that absence
from the workplace will not be left
unregistered. A record will also help
you spot any patterns - for example,
the one individual who often takes a
Thursday off, when you know that a
few employees regularly go for drinks
together on a Wednesday night.
Any absence should always be
followed up with a return to work
interview. This will give you the
opportunity to speak privately to
the employee on their first day back.
Try to find out as much as you can
about the employee’s recovery
progress, their symptoms and
whether they visited a doctor.
Persistent absence
Persistent absence can amount to
a disciplinary offence and your
disciplinary procedure should
cover this.
It may be worth reviewing your
disciplinary procedure and ensuring
all staff members are aware of it.
Employee Assistance
Programmes
Finally, Employee Assistance
Programmes are designed to offer
telephone or face-to-face counselling
support to employees on a wide
range of issues from money, to stress,
to childcare. The counselling offered
could prove invaluable to an
employee who may be able to resolve
issues in this way rather than falling
into the trap of thinking that time
off is the answer.
Long periods of absence
As part of the GROUPCARE
scheme, practice managers can
call the 24-hour Peninsula
employment law advice line free
for further information on dealing
with complex employee situations
or guidance with resolving
employment law matters.
Ring 0844 892 2772, quoting your
MDU membership number,
GROUPCARE number and
Peninsula authorisation code
MDU001.
Stress and depression are a common
cause of longer periods of absence.
This is a recurring theme in calls to
the Peninsula employment law
advice line from MDU members.
Clearly some job roles are linked
with a more highly pressured
environment than others. When
absence becomes long-term, it is
useful to refer the employee to an
occupational health specialist who
is able to give a prognosis as to the
employee’s chances of returning
to work.
If the reason for absence is classed
as a disability, the Equality Act 2010
requires that employers look at any
reasonable adjustments that can be
made to enable the employee to
perform their role.
Reference
1
Time off for sickness.
http://bit.ly/inpractice15
7
Feature
CQC
For Practices in England only
Prepare
for
– with the
MDU guide
TO CQC
After years of anticipation, and at least one false start, CQC registration
for primary care is now with us. By the end of 2012, every qualifying GP
practice and primary care organisation in England must have applied
for registration. CQC will then process the applications and, by 1 April
2013, should have informed all practices whether their application has
been successful and they are CQC-registered.
Completing the application form should be straightforward. The practice
has to show that it is compliant, or working towards compliance, with
CQC’s 28 essential standards (or ‘outcomes for patients’). At the time of
your application, you may be compliant with many, but perhaps not all
of them. CQC says this will not be a bar to registration providing there
is no risk to patient safety.
The devil is in the detail, of course. When CQC checks a practice’s
application for registration, they will do so against 16 out of the 28
essential standards that are designated ‘core’ outcomes – that is, those
which relate directly to patient safety. CQC says you must have evidence
that you meet these outcomes, or that you can show you are taking
action towards compliance.
What evidence will you need?
CQC has published a list of ‘prompts’ against each outcome to help
healthcare providers understand what CQC expects of them1. Primary
care organisations and GP practices are expected to assess their
procedures against the prompts. Where you comply with an outcome,
you should be able to produce evidence to support your compliance,
or state what actions you are planning to take.
T
his autumn, all
primary care practices
in England will be
going through the process
of applying for registration
with the Care Quality
Commission (CQC).
The MDU has developed a
helpful interactive online
guide to assist you with your
preparations and beyond*.
8
However, the CQC doesn’t specify what evidence they might expect to
see, and it isn’t always easy to see what action you might need to take if
you aren’t currently compliant. This is where the MDU Guide to CQC
will help.
Feature
The MDU Guide to CQC
The MDU Guide to CQC is a step-by-step guide to
support practice managers and GP partners in reviewing
how their practice meets the essential standards set out
by the CQC. The guide has been developed jointly by
our medico-legal advisers with extensive experience of
general practice, and Peninsula, who have expertise in
employment and human resources. The guide takes you
through each of the 28 outcomes in detail, with a series
of questions to consider.
How to access the guide
MDU GROUPCARE
scheme members can
access the MDU Guide
to CQC by visiting
the-mdu.com/cqc
The guide will;
• Give you relevant medico-legal and regulatory
information and suggest examples of documents
that may provide evidence of compliance.
• Enable you to produce an action plan, with a list of
outstanding actions for compliance.
• Create a report to record your answers and progress,
which can be printed or downloaded for your records.
• Save your answers as you progress, to be completed
at your convenience.
If you are not currently a GROUPCARE scheme
member but would like to benefit from the MDU
Guide to CQC, please visit the-mdu.com/groupcare
for details on how to set up a scheme.
‘The MDU Guide is designed to take the fear out of
applying for CQC registration for GPs and practice
managers,’ says Dr Matthew Lee, MDU professional
services director. ‘It’s simple to use and full of additional
information to help practices get the most from their
initial application. Once registered, they can use it to
maintain their compliance and to support their
preparation for periodic CQC inspections.’
‘We should stress, of course, that the guide is a support
tool. Practices will still have to apply for registration
through the CQC website. But identifying and collating
the background information beforehand should make
the completing CQC application a smoother and,
hopefully, quicker process.’
CQC inspections
The CQC has said that it will start to inspect
primary care organisations and GP practices after
April 2013. During an inspection, the inspectors
will talk to staff and patients about the practice.
It is important that staff fully understand, and
can articulate, your practice procedures and
protocols. The MDU Guide gives helpful pointers
on where staff training would be helpful, and
where it may be advisable draw up a written
protocol or include information in your staff
handbook.
*Available at the-mdu.com/cqc for GROUPCARE
scheme members only.
Reference
1
The CQC essential standards.
http://bit.ly/inpractice17
9
Feature
Creating a
healthy
workforce:
Managing change
Managing staff well-being
through periods of change
can be difficult, especially
in smaller organisations that
do not have dedicated
human resources. Ben
Amponsah, head of
operations at Peninsula
Business Services reveals
some of the secrets of
creating and maintaining a
health, happy workforce
during stressful times.
T
he current rate of change in
general practice is breathtaking,
and the pressure on practice
managers is intense. Not only must
you keep up with the many
regulatory and procedural changes
while juggling the day-to-day work
of a busy practice, you also have to
ensure staff are healthy, balanced
and resilient throughout these
testing times.
To promote and implement
change effectively, it’s important
to understand why change can
be difficult for many people. We
appreciate a degree of predictability
in our lives, such as going to work
and expecting to see the same
people everyday, to sit in the same
chair and complete work that is
familiar. Daily routines give us
comfort, and although some days
may be different and busier than
others, we feel confident about what
is expected of us and how we will
accomplish the tasks we are given.
10
Any kind of change can disrupt this
predictability and comfort, and can
cause distress among employees.
Some people adapt to change easily,
while others are sceptical from the
first hint of change. For a practice
manager, the challenge is to
implement necessary changes
without creating a stressful
environment. You may never be able
to fully predict the impact of change
on the practice work environment
and culture, but there are some
pointers that may help you
prepare yourself and your employees
for change.
Clarity of planning
Before embarking on any programme
of change you must be clear about:
• The business need for the change,
so you can explain this to staff
members and help them see why
Feature
the change is needed.
• The specifics of the change,
so you can speak clearly and
concisely on what will happen.
• The benefits of the change,
so you can sell in the positive
effects the changes will have.
• The impacts of the change,
so you can demonstrate that
the impacts have been assessed
and any threats or disruption
have been addressed.
Chances are the more informed,
certain and organised you are,
the more your staff will trust you,
and the change itself.
Leadership
Managing change isn't enough
- you have to lead it. Change is most
successful when the whole company
is dedicated to the change – and
that requires strong leadership
and support from everyone who
is responsible for making the
change happen.
As a leader, how will you address
the emotional aspects of change?
You will need to communicate
clearly and openly and speak
honestly about any repercussions of
the change. Consider the following
points, which could be communicated
during team meetings and catch-ups.
•
•
•
•
What exactly is changing?
What will be different?
Who will be affected?
Emphasise the positive aspects of
the change, and the efficiency it
may bring.
Communication and
listening
You can never ‘over-communicate’
when leading and managing
change in the workplace, clear
communication is essential.
You will need to show you actively
listen to feedback and complaints
from employees, as well as
demonstrating that you have
thought about the implications of
change through ideas and briefings.
Think of change as a two-way street,
with information flowing both
ways. Consider holding regular
meetings or sending a news
bulletin to keep all those involved
informed.
Capability and
resources
It is important that you ensure
your staff have the capabilities
and resources to manage change.
Achieving a healthy balance in the
workplace is one of the best ways
of building resilience and therefore
capability in managing stress and
change. You can implement
Employee Assistance Programmes,
or a company sponsored scheme
such as fitness or healthy eating.
All these resources will have an
impact on the individuals’ wellbeing, and may also affect the
impact the change has on them.
The face of the NHS is constantly
changing, and the pressure to ‘get
it right’ has never been greater.
Equally, there has never been a
better time to assess the way your
practice deals with change to ensure
staff remain informed, content,
stimulated and motivated.
FREE 24-hour
employment law advice line
GROUPCARE* members have access to an employment law
advice line provided by Peninsula Business Services, the UK’s
leading provider of employment law and health and safety
services – completely free, consisting of:
• A help desk available 24/7, providing guidance in
resolving all kinds of employment law issues
• Dedicated consultants with in-depth experience in
employment legislation, contractual requirements
and case law precedents
• Telephone coaching in managing difficult or complex
employee relation issues.
To find out more, or for more information about
GROUPCARE, contact the GROUPCARE team on
0800 012 1318 or visit the-mdu.com/groupcare
*GROUPCARE is open to all practices with at least two eligible GPs who are current MDU members.
11
MDU Services Limited (MDUSL) is authorised and regulated by the Financial Services Authority in respect of insurance mediation activities only. MDUSL is an agent for The Medical Defence Union Limited (the MDU). The MDU is not an insurance company.
The benefits of membership of the MDU are all discretionary and are subject to the Memorandum and Articles of Association. MDU Services Limited is registered in England 3957086. Registered Office: 230 Blackfriars Road, London, SE1 8PJ.
© MDU Services Limited 2012.
Criminal records case study
Feature
Medical records are essential for patient care
and the processes to manage records are
increasingly under scrutiny. Dr Kathryn Leask,
MDU medico-legal adviser, examines the legal
and regulatory issues.
T
he recent spate of data
breaches resulting in
substantial fines from the
Information Commissioner (see News
in brief) serve as a timely reminder
that confidentiality, security and
storage of patient medical records is
paramount – and may easily go awry.
The duties and responsibilities of GP
practices to manage patient medical
records appropriately and carefully
are governed by legislation and GMC
ethical guidance.
The Data Protection Act 1998 (DPA)
is the main law relating to the
processing of data, and covers the
collection, storage, destruction and
use of confidential patient data.
The Act applies to both computerised
personal data and hard copy paperbased files.
T
A health record is defined as any
information which relates to a
patient or made by or on behalf
of a healthcare professional,
which includes nurses, health
visitors or midwives.
The DPA sets out eight data
principles that define how personal
information must be handled.
1. The information should be
obtained fairly and lawfully and
should only be processed if the
data subject has given consent
or there is a legal requirement,
and in the best interests of the
data subject.
2. The information should be
obtained for only one or more
specified lawful purposes and
not used or disclosed for a reason
which is not compatible with this.
3. The information should
be adequate, relevant and not
excessive.
4. In addition to the above, it should
be accurate and where necessary
kept up to date.
5. Information should not be kept
for longer than necessary.
6. Personal data should be processed
in accordance with the rights of
the data subjects under this Act.
This means the data subject can
request access to their records, as
can a legal representative or any
one with parental responsibility
for a minor.
7. Information must be safeguarded
from unauthorised or unlawful
processing or accidental loss
or damage.
8. Information should only be
transferred to countries that
offer adequate data protection.
The Access to Health Records Act
(1990) relates to the records of
deceased patients and sets out the
legal requirements in relation to
he police approached a GP requesting contact details for a
patient they were investigating in connection with a crime.
They also wanted to know when the patient had last visited
the surgery.
The police explained that under the Data Protection Act 1998 section 29(3), personal data is exempt
from the usual non-disclosure provisions when it is required specifically for the prevention or detection of a serious
crime and suggested that consent was not necessary. Concerned about disclosing this information without his
patient’s consent, the GP called the MDU.
The MDU adviser explained that while section 29(3) allows a data holder to disclose information, it does not require
him to disclose it and even if the request is from the police, the doctor’s legal and ethical duties of confidentiality still
apply. A patient’s identity, contact details and attendance dates are all confidential and can only be disclosed with the
patient’s consent.
Disclosure without consent may be justified if it is in the public interest to do so, but the police had given the doctor
no grounds for breaching his duty of confidentiality. He explained this to the police and they withdrew their request.
12
Failure to record case study
Membership
Feature
A
patient claimed that a GP’s failure to arrange for him to undergo a repeat blood glucose test and to treat
his diabetes mellitus resulted in his suffering an acute myocardial infarction.
The 45 year old male patient had a routine urinalysis test done for an insurance medical. This showed
glycosuria, and a fasting blood glucose test suggested diabetes mellitus.
The blood glucose result was reviewed by the GP, who arranged for the patient to be contacted by telephone
by one of the receptionists. The patient was advised to re-attend for a further fasting serum glucose test, in
accordance with the practice’s usual procedure. The call was not documented. The patient did not attend the
follow-up appointment, but was seen by a different GP six weeks later for another matter. Having reviewed
his notes, the GP reminded the patient of the need for a repeat fasting blood glucose sample.
Unfortunately, this reminder was not recorded in the medical records. The patient did not attend again until
another month had passed. On this occasion he complained of chest pain. The GP suspected myocardial
ischaemia and arranged immediate hospital admission. An acute myocardial infarction was confirmed.
The patient’s blood sugars were raised and he was diagnosed as diabetic and started on insulin. Two years
later, the two GP members received a letter of claim. The allegations were that there was a failure to arrange
for the claimant to undergo a repeat blood glucose test and a failure to diagnose and treat the claimant’s
diabetes mellitus. It was alleged that if this had been treated, the acute myocardial infarction would have
been avoided.
This case illustrates the importance of documenting all encounters with patients whether this is with a
member of clinical staff or administrative staff within the practice.
disclosure of information after a
patient’s death. The GMC also
provides guidance for doctors in
relation to this in their booklet on
confidentiality1.
Confidentiality
The MDU receives numerous
requests for advice each year from
members regarding disclosure of
confidential information to third
parties. Disclosures may be sought
by relatives, solicitors or other
organisations, such as social
services. If members are in any
doubt as to whether disclosure
without consent is appropriate they
should contact the MDU for advice.
Clear, accurate, full notes
In relation to the content of the
clinical record, the GMC states in
Good Medical Practice paragraph 3:
In providing care you must:
(f) keep clear, accurate and legible
records, reporting the relevant
clinical findings, the decisions made,
the information given to patients,
and any drugs prescribed or other
investigation or treatment.
Although this guidance applies to
doctors registered with the GMC it
is increasingly common for other
members of staff at the practice to
record entries in the patient’s
clinical record. This will help ensure
that clinical staff involved directly in
the care of the patient are fully aware
of other interactions the patient may
have had at the practice.
New guidance produced by the
GMC2 adds to the ethical obligations
in Good Medical Practice,
particularly for those doctors who
have extra managerial responsibilities.
All doctors are expected to be
familiar with policies where they
work in relation to confidentiality
and record management policies
and procedures. Doctors with extra
responsibilities must also ensure
that all records, including financial,
management or human resources
records or those relating to
complaints, are clear, accurate and
up to date and that data is handled
in line with the DPA.
Practices must also ensure
compliance with Care Quality
Commission (CQC) outcome 21
regarding records. The outcome
closely reflects the principles set out
in the DPA and requires that
patients are confident that their
personal records, which include
medical records, are accurate,
confidential and held securely.
Practices are expected to ensure the
accuracy of records in relation to
personalised care and treatment in
addition to storing them in a secure
but accessible way so that they can
be located quickly when required.
Records must be retained for at least
the minimum periods set out in the
relevant retention schedule and if
they are to be destroyed, this must
be done securely. Practices are likely
to be compliant with the CQC
outcome if they follow the
Department of Health’s Records
Management NHS Code of Practice.
References
1
2
GMC: Confidentiality (2009).
http://bit.ly/inpractice18
Leadership and management for all
doctors (2012).
http://bit.ly/inpractice19
13
Practicedilemma
Prescribing
Errors
In May 2012 the GMC published
research it had commissioned
from Nottingham University on
GP prescribing. This research
suggested that one in 20 GP
prescriptions contains an error,
and for one in 550 that error is
potentially severe1. Dr Sally Old,
medico-legal adviser, describes a
fictional practice dilemma, and
explains how you can reduce
prescribing errors.
In the GMC-commissioned study,
distractions and a failure to utilise
IT systems for safe prescribing were
noted as factors that might increase
the possibility of a prescribing error.
The most common prescribing
errors were in relation to dosage,
with either missing or incorrect
information being supplied, or in
relation to a failure to ensure the
necessary monitoring of safety
and/or efficacy of the drug through
blood tests. The researchers
emphasised the importance of
pharmacists supporting GP
prescribing, better use of computer
systems and appropriate education
for trainee GPs.
Sharing experiences
Professor Tony Avery of the
University of Nottingham’s medical
school, who led the research, said:
‘Few prescriptions were associated
with significant risks to patients but
it’s important that we do everything
we can to avoid all errors. GPs must
ensure they have ongoing training in
prescribing, and practices should
ensure they have safe and effective
systems in place for repeat
prescribing and monitoring. I’d also
encourage doctors to share their
experiences of prescribing issues
both informally within their
practices, and also formally where
appropriate through local or
national reporting systems.
14
A
recently registered patient visited a GP with a chest infection, and was
given a prescription for amoxicillin. The patient later returned to
reception. She had taken her prescription to the pharmacy where the
pharmacist had questioned whether she had a penicillin allergy. The patient
was indeed allergic to penicillin and complained that the doctor she visited
had been distracted by a phone call during the consultation, and she felt he
should have known about her allergy.
The practice manager acknowledged her complaint and apologised. The GP
made a note of the allergy on the computer records and a completed
significant incident form. The patient was informed that these changes had
happened and left with her new prescription.
The incident was discussed at the next practice meeting and the clinicians
were reminded to enquire about allergies and complete the allergy
information on the computer record system. Support staff were told that
although some interruptions during consultations were unavoidable, they
should be kept to a minimum.
Prescribing is a skill, and it is one
that all doctors should take time to
develop and keep up-to-date.’
Effective computer systems
Commenting on the research,
Prof Sir Peter Rubin, Chair of the
GMC said;
‘GPs are typically very busy, so we
have to ensure they can give
prescribing the priority it needs.
Using effective computer systems to
ensure potential errors are flagged
and patients are monitored correctly
is a very important way to minimise
errors. Doctors and patients could
also benefit from greater involvement
from pharmacists in supporting
prescribing and monitoring.’
Current guidance
Later this year the GMC is expected
to publish an update on its 2008
guidance for doctors, Good practice
in prescribing medicines. The current
guidance2 reminds doctors
(paragraph 6) that they should:
a. Prescribe dosages appropriate for
the patient and their condition.
b. Agree with the patient
arrangements for appropriate
follow-up and monitoring where
relevant. This may include:
further consultations; blood tests
or other investigations; processes
for adjusting the dosage of
medicines, changing medicines
and issuing repeat prescriptions.
c. Inform the Committee on the
Safety of Medicines of adverse
reactions to medicines reported
by your patients in accordance
with the Yellow Card Scheme.
Doctors should provide patients
with information about how to
report suspected adverse reactions
through the practice.
d. Make a clear, accurate, legible and
contemporaneous record of all
medicines prescribed.
Of course, many nurses are now also
prescribers in their own right. The
NMC Code of Practice3 states that
nurses must recognise and work
within the limits of their competence
and deliver care based on best
available evidence or best practice.
Nurses are also required to keep clear
and accurate records including any
medicines prescribed and how
effective they have been.
With all English GP practices
needing to register with the CQC,
practices may also wish to bear in
mind that the CQC cites as its ninth
outcome ‘People should be given the
medicines they need when they need
them, and in a safe way’.
References
1
2
3
GP prescribing errors research.
http://bit.ly/inpractice20
GMC’s Good practice in prescribing
medicines - guidance for doctors (2009).
http://bit.ly/inpractice21
The code in full. http://bit.ly/inpractice22
Membership
New End of life care
seminar
M
any of the day-to-day activities
of primary care come together
when a patient approaches the end
of their life. In response to a number
of requests from members, the MDU
has developed a new practice-based
training seminar on this topic and
the many ethical issues it poses.
Nursing duties:
update your records
For many MDU members the
calculation of their MDU
subscription is based on the type of
work carried out. This applies not
only to our medical members but
also to the registered nurse members
of the practice. It is important that
the records the MDU keep are
updated with the most recent
Save up to 30%
on selected
Oximeters
P
ulse oximeters are increasingly
valuable in the GP setting.
Although widely available in
operating theatres, A&E
departments and most hospital
wards, as well as in ambulances,
not all UK GPs have access to pulse
oximeters when assessing acute
medical patients in the community.
A recent survey in the UK suggested
that over a third of GP surgeries do
not own a pulse oximeter1. However,
it is likely that this will change as
these small, portable, battery
operated devices can provide
accurate quantitative values for
oxygen saturation which otherwise
can be assessed only by the presence
or absence of cyanosis, a physical
sign unreliable even in good light.
Available FREE of charge to
information about their working
circumstances and responsibilities.
The MDU considers nursing
members who carry out the
insertion of contraceptive implants,
for example, to be acting in an
extended role and they will fall into
a higher risk category. Nursing
members who are prescribing
independently, assessing and
deciding on the treatment of patients
and/or performing procedures
GROUPCARE members and
designed to address the needs of the
entire healthcare team, the MDU’s
practice-based training seminars are
highly interactive and stimulating
and facilitated by one of our GP
liaison managers in your practice,
at a time to suit you.
For more information about these
seminars, simply ask your local
GP liaison manager or visit
the-mdu.com/seminars
not normally undertaken by
nurses may fall into a separate
membership category.
To update us on the current
responsibilities and circumstances
of nurses in your practice, contact
the MDU membership helpline
on 0800 716 376 (8am to 6pm
Monday to Friday) or email
[email protected]
All oximeters also provide a pulse
rate read-out.
Their clinical uses include:
• Grading the severity of acute
asthma2.
• Assessing the oxygen requirements
of patients with communityacquired pneumonia3.
• Identifying patients with COPD
who might benefit from assessment
for long-term oxygen-therapy4.
The MDU has teamed up with
Williams Medical Supplies, the
leading provider of medical supplies
and services to the UK healthcare
market, to offer MDU members an
exclusive discount of up to 30% on
a selection of pulse oximeters.
Discount offer
Visit the member discounts page
of the MDU website and click on
the oximeter you want. You will be
redirected to an MDU member
only section on the Williams
Medical Supplies website where
you can find out more about the
product and place an order.
Alternatively, please call the
Williams Medical Supplies Sales
Hotline on 01685 846666 and
quote ‘MDU’.
References
1
Menzies S, Wiggins J. A survey of pulse oximeter use by general practitioners in East Berkshire, UK. Poster
session presented at: The European Respiratory Society, Annual Congress, 27 September 2011.
2 The BTS-SIGN British Guideline on the Management of Asthma (revised 2011), British Thoracic Society.
www.brit-thoracic.org.uk
3 Guidelines for the management of community acquired pneumonia in adults (revised 2009), British Thoracic
Society. www.brit-thoracic.org.uk
4 Management of COPD in adults in primary and secondary care, clinical guidelines 101, (June 2010), National
Institute for Health and Clinical Excellence. http://guidance.nice.org.uk/CG101
15
Your feedback
Please give us your feedback about the MDU at
the-mdu.com/feedback
or email [email protected]
UK
GP liaison managers
Paul Archer - team manager
[email protected]
Carolyn Barrett - North Thames
[email protected]
Vanessa Jack - South Thames
[email protected]
Mel Davies - South Wales
[email protected]
David Ireland - South West
[email protected]
24-hour freephone advisory helpline
0800 716 646
freephone membership helpline
0800 716 376
calling from mobile or overseas
+44 (0)20 7022 2210
freephone GROUPCARE helpline
0800 012 1318
calling from mobile or overseas
+44 (0)20 7022 2211
Samantha O'Gram - North East
[email protected]
Chris Hall - North West
[email protected]
Gina Wade - Anglia & Oxford
[email protected]
Donald Worthy - West Midlands
[email protected]
Nasir Ahmed - East Midlands
[email protected]
advisory email
[email protected]
membership email
[email protected]
GROUPCARE email
[email protected]
website
the-mdu.com
@The_MDU
MDU Services Limited
230 Blackfriars Road London SE1 8PJ
© MDU Services Limited 2012.
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