Volume 8 Issue 2 October 2012 ISSN 1749-3595 Creating a healthy workforce: Managing change Supporting your business We tailor our corporate solution to fit your business rather than the other way around. Understanding your needs and those of your organisation is at the heart of the way we work. Our solutions continually evolve to meet the ever changing needs of your business and the healthcare market. For more information visit the-mdu.com/corporate or call the freephone membership helpline on 0800 716 376. Protecting your business 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. Advice to hand You can now get expert medico-legal advice from the MDU, wherever you go with our new iPhone and iPad app. The app includes our guidance on: - Confidentiality - Coroner’s inquiries - Handling complaints - Clinical negligence Plus the latest issues of inpractice Search for MDU Now you can have the latest advice to hand – wherever you are 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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