Q A patient recently attended our practice to consult with a GP who called him to the consultation room using the tannoy function installed in the new telephone system. However, the doctor failed to switch off the tannoy and the first few minutes of the consultation were broadcast for the whole waiting room to hear. The doctor reassured the patient at the time that he should not worry because no particularly sensitive matters had been discussed. The patient has since made a complaint and, as practice manager, I am unsure how best to proceed.
A As with all complaint responses, it is important to acknowledge that a mistake was made, to apologise for the distress caused and to offer a full explanation of how things went wrong. You should also take steps to ensure a breach of confidentiality like this does not happen again, and to reassure the patient of this. You should certainly not seek to dismiss their concerns: in this case, it seems unwise to simply tell the patient “not to worry”. Be sure to discover what went wrong with the phone system in this instance and make sure that in future all staff are aware of how to operate it, particularly when a tannoy function is available. MDDUS can assist with the drafting of written responses tailored to each individual complaint and provide further advice and support should the case escalate.
Q A couple of our practice employees regularly work overtime and I have heard them mention that they will soon be entitled to more holiday pay because of a recent employment tribunal ruling. Will the practice have to start paying them more?
A Yes. The long awaited judgement on the Bear Scotland & ors v Fulton & ors (and related cases) has held that holiday pay calculations should include regular overtime, even non-guaranteed overtime. The judgment only applies however to four weeks under the Working Time Directive and not the additional 1.6 weeks granted in the UK and may be subject to appeal. Any members who have questions on this please contact the MDDUS employment law advice team.
LOST IN TRANSLATION
Q A patient from Poland recently came into the practice for dental treatment but did not speak very good English. One of our nurses is Polish and speaks very good English and it was agreed he would translate what the dentist was saying. The patient has since complained about his finished treatment, claiming he did not expect his teeth to look the way they do. The dentist also did not note any details of the process of translation or consent. How should we proceed in future?
A When treating patients with limited English, ideally a professionally qualified interpreter should be used. They should be told beforehand that the dentist must hear all information offered by the patient and that everything the dentist says should be translated for the patient. Check the patient is comfortable before proceeding and clearly record in the notes that an interpreter is present, including their name and contact details. It should also be noted that the patient has consented to the arrangement and a clear account given of the information shared during the consultation. Extra care should be taken when using a non-professional interpreter – relatives/friends are often not appropriate as there is no way of knowing their grasp of the language and they could undermine confidentiality. They may also lack objectivity and be unfamiliar with clinical terminology. Take care also when using a practice staff member to translate as they may not be sufficiently skilled for the task. For valid, informed consent, it is vital to confirm the patient has understood the information given and is happy with the proposed course of treatment.
Q A number of our patients frequently do not attend for reviews or monitoring of their medication. To what extent are we expected to keep contacting these patients to encourage them to come in?
A It is important to explain to patients the benefits of attending for review and the risks of not doing so, ensuring they have sufficient capacity to understand and make their own decisions on the matter. Be sure to clearly document all attempts to contact the patient and the advice given to them about non-attendance. Practices should have a clear policy on dealing with DNAs, with a system in place to identify patients who fail to attend and a means of dealing with those who cause concern. There should be a prompt investigation of why a patient has not attended as some vulnerable patients may need extra support/advice. It would be for the GP to exercise their clinical judgement as to whether repeat prescriptions should be ended for repeat non-attenders, taking into account the GMC guidance on this issue.
Q One of our patients has made a large number of complaints over the past two years about various aspects of his clinical care as well as criticising the practice appointments system and the behaviour of some of our staff members. He has just submitted yet another complaint and I feel it may be better if he was removed from the practice list and encouraged to find another GP.
A The decision to remove a patient from the practice list must be made very carefully. Guidance from the RCGP and GMC is clear that you should not end a professional relationship with a patient solely because of a complaint the patient has made about you or your team, or because of the resource implications of the patient’s care or treatment. There is a clear process to be followed, one which must be fair and reasonable and does not discriminate against the patient. Usually removals are made where the relationship between the practice and the patient has broken down, often as a result of aggressive or violent behaviour. GMC guidance also provides for removal in situations where a patient has “persistently acted inconsiderately or unreasonably,” leading to a breakdown of trust between doctor and patient. Before removal, you should warn the patient of your intentions and do what you can to restore the relationship. If the decision to remove is taken, inform the patient in writing (explaining the reasons why) and note this in their record. Be sure to give the patient information on finding another GP.
Q I have recently started work managing a medical practice and have been checking compliance with infection prevention and control requirements. I notice one of the waiting rooms still has carpeting on the floor. Is this a problem?
A Each clinical commissioning group (CCG) or health board area will have its own infection prevention and control policies and you should consult the relevant policy for your area. Generally, carpeting is not recommended in any clinical areas (particularly not treatment rooms) or patient waiting areas due to the risk of body fluid spills. Any other carpeted areas should be well vacuumed and cleaned regularly in line with local policies. This should be set out clearly within the practice’s written cleaning schedule. Practices in England and Wales will have to comply with requirements of their registration with the Care Quality Commission (CQC) while those north of the border are inspected by Healthcare Improvement Scotland.
Q One of our practice staff members has turned up to work recently smelling strongly of alcohol and her appearance is sometimes dishevelled. She has made an increasing number of errors lately and I am concerned she has a drink problem which could impact on patient safety.
A If you believe a staff member is under the influence of alcohol then it must be addressed immediately. Ask her about it in a confidential setting, focusing on the workplace performance issues and giving clear examples of where errors have been made. If she denies it, then give clear timescales for improvement and offer extra support and training. If she admits to a problem, offer to refer her to a counselling or AA group, as well as focusing on the errors. It should be made clear that being drunk at work will not be tolerated and can be a dismissible offence. Where an employee is clearly drunk at work, consider sending them home on paid leave while the matter is investigated. A clear, up-to-date practice policy on alcohol use is essential. It may also be worth involving occupational health services.
Q The social worker of a 15-year-old patient, who suffers mental health problems, has contacted the practice seeking access to his medical records in order to update his file. The GP asked for evidence of written consent from the patient and the social worker has sent back a consent form dated almost two years ago. Is this still valid?
A It would be reasonable to conclude that a consent form signed so long ago is now so old as to be no longer valid. While there is no official time limit on consent taken in advance of treatment or for other purposes, such as third party disclosure of confidential information, it would be advisable to review it in this case. The GMC encourages decisions about treatment to be reviewed where “significant time has passed since the initial decision was made” as patients have the right to change their mind at any time. Ask the social worker for an up-to-date consent form before releasing the patient records.
Q A patient has asked to amend their record because they believe the information to be incorrect. Are they allowed to do this?
A Under the Data Protection Act 1998, patients have the right to request amendments to their records. This includes correcting simple errors, but can also extend to redacting sensitive details or more complex disagreements over clinical content. In this case, if the doctor agrees with the proposed amendment (that there is, in fact, a mistake/inaccuracy in the patient’s record) then the amendment can be made. A contemporaneous entry should also be made to indicate what has been altered and why. If the doctor does not agree that the record should be amended, an offer can still be made for an additional entry to be made in the records noting the patient’s view/disagreement with the contents. When amending paper records, be sure not to obliterate the piece of information that is being amended. Cross it out with a single line and add the amendment, including an explanation of why the amendment has been made.