going for gold - medical protection · the countdown has begun for you to register with the cqc by...

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PAGE 6

Going for Gold

Countdown to CQC rEGistrAtion

managing nurse telephone triage

Assessing fitness to drive

Risks of prescribing

Inside this issue:

PRofessionAl sUPPoRt And exPeRt Advice foR gP PRActices

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UK-YP_FULL_Vol6-Iss2_Jun12.indd 1 06/06/2012 10:46

MPS General Practice Conference 2012

London | Thursday 14 June | The King’s Fund

Liverpool | Thursday 21 June | Crowne Plaza Hotel

Bristol | Tuesday 26 June | At-Bristol

MPS’s 2012 annual general practice conference will explore where the real risks lie in primary care and take an in-depth view of some specific areas of risk. Delegates will experience a combination of plenary sessions, Q&A panels and streamed workshops exploring different aspects of medicolegal risk and ethical challenges arising from clinical practice in primary care.

■ Regulation and redress■ The changing sources of risks –

commissioning, continuity of care and vicarious liability

■ Claims trends – The MPS experience■ Confidentiality and information sharing

■ Challenging patient interactions – Boundaries and breaking bad news

■ Human factors and systems errors■ Workshops on: Medicolegal Hot Topics,

Reducing an Escalating Complaint, and Employment Law in Practice.

Topics covered include:

For more information and to register visit: www.mps.org.uk/gpMPS1397:02/12

MediCaL ProTeCTion SoCieTyEduCATion And riSK MAnAgEMEnT


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Welcome

get the most fRom yoUR membeRshiP

Visit our website for publications, news, events and other information:www.mps.org.uk

Follow our timely tweets at:www.twitter.com/mPsdoctors

Inside this issue of Your Practice…

We welcome contributions to Your Practice. Please contact us

on 0113 241 0377 or email [email protected]

dr Richard stacey – Editor-in-chiefMPS Medicolegal Adviser

opinions expressed herein are those of the authors. Pictures should not be relied upon as accurate representations of clinical situations. © the medical Protection society limited 2012. all rights are reserved.

GloBe (logo) (series of 6)® is a registered uK trade mark in the name of the medical Protection society limited.

cover: © Peter muller / scIence PHoto lIBrarY

6

editoR-in-chief Dr richard stacey editoR sara Williams contRibUtoRs Julie Wilson, cQc, nIce, Diane Baylis, mark Jordan, st Georges medical centre, mPs education and risk management design allison Forbes PRodUction mAnAgeR Philip Walker mARketing Jo naylor, Kirsten Wilson, Beverley Hampshaw editoRiAl boARd Dr stephanie Bown, Gareth Gillespie Your Practice medical Protection society, Granary Wharf House, leeds, West Yorkshire ls11 5PY tel: 0113 241 0530 Fax: 0113 241 0500

the countdown has begun for you to register with the cQc by 1 april 2013 – this includes those providers of General medical services (Gms), Personal medical services (Pms) and alternative Provider medical services (aPms). From July you will receive an invitation from the cQc to begin the application process (registration) – you will then be able to choose a date between september and December 2012 to submit your online application.

In the application you will be asked to state whether or not you are compliant with the Essential Standards of Quality and Safety. mPs is aware of practices who are cautious about how to demonstrate compliance with these standards and have sought advice from mPs.

In her article “Going for Gold”, mPs’s clinical risk manager Julie Wilson shares her tips to help you successfully register with the cQc. she will explore the cQc registration process further at the mPs General Practice conference 2012 – Where the risks lie. Visit www.mps.org.uk/gp for more information.

this issue also boasts an interesting feature from Diane Baylis, on how to safely manage nurses who perform telephone triage. Face-to-face appointments with a doctor come at a high cost, but it is important that nurse triage is not simply introduced as a way to save money. that said, if it is introduced safely and managed effectively, it can be a valuable resource for a GP surgery.

We hope you enjoy this issue.

4 UpdateIn this issue, read about Professor tony avery’s

study, which revealed that one in 20 prescriptions

contains error

6 going for goldthe countdown to cQc registration has begun.

Julie Wilson shares some tips to help practices

jump through those tricky final hoops

9 legal eye mPs solicitor mark Jordan describes a case

where a defamatory claim against a doctor was

successfully struck out

10 nurse telephone triage Diane Baylis explores the risks of nurses

performing telephone triage 10

MPS is aware of commercial organisations

that have approached practices offering to provide a

service in relation to the provision of ‘reminder’ letters for specific target groups, eg, influenza vaccination reminders for diabetic patients.

On the face of it this may appear to be an attractive service. However, MPS has significant concerns in relation to issues around consent and confidentiality, given that this will necessitate the disclosure of personal information to a commercial organisation.

In their publication Confidentiality, the GMC do explain that most patients understand and accept that information must be shared within the primary care healthcare team in order to provide their care (paragraph 25).

Patients may (reasonably) object to information about their health being shared with a commercial organisation without their consent and in the above publication, the GMC states that when providing patients with information in relation to the way their personal information is used, you should consider whether patients would be surprised to learn about how their personal information is being used and disclosed.

If your practice is considering engaging the services of such a commercial organisation then you should seek MPS advice before proceeding.

For more read the GMC’s Confidentiality (2009) – www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp

beware of using external agencies to send out reminder letters

MPS is aware of commercial organisations

that have approached practices offering to provide a MPS General Practice Conference 2012

London | Thursday 14 June | The King’s Fund

Liverpool | Thursday 21 June | Crowne Plaza Hotel

Bristol | Tuesday 26 June | At-Bristol

MPS’s 2012 annual general practice conference will explore where the real risks lie in primary care and take an in-depth view of some specific areas of risk. Delegates will experience a combination of plenary sessions, Q&A panels and streamed workshops exploring different aspects of medicolegal risk and ethical challenges arising from clinical practice in primary care.

■ Regulation and redress■ The changing sources of risks –

commissioning, continuity of care and vicarious liability

■ Claims trends – The MPS experience■ Confidentiality and information sharing

■ Challenging patient interactions – Boundaries and breaking bad news

■ Human factors and systems errors■ Workshops on: Medicolegal Hot Topics,

Reducing an Escalating Complaint, and Employment Law in Practice.

Topics covered include:

For more information and to register visit: www.mps.org.uk/gpMPS1397:02/12

MediCaL ProTeCTion SoCieTyEduCATion And riSK MAnAgEMEnT


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these are provisional publication dates. to keep up-to-date with the latest developments from nice, sign up to receive the newsletter, visit www.nice.org.uk or follow nice on twitter (nicecomms).

Month tYPE GuidancE

June 2012clinical guideline

autistic spectrum conditions in adults

osteoporosis fragility fracture risk

Venous thromboembolic diseases

July 2012

Public health guidance

Preventing type 2 diabetes – risk identification and interventions for individuals at high risk

technology appraisals guidance

migraine (chronic) – botulinum toxin type a

thromboembolism (treatment and long term secondary prevention) – rivaroxaban

August 2012clinical guideline

Incontinence in neurological disease

lower limb peripheral arterial disease

neutropenic sepsis

confeRences And eventsevent When WheRe WhAt UsefUl links

mPs gP conference 14 June, 21 June, 26 June

london, liverpool, Bristol

set to explore where the risks lie in primary care

www.mps.org.uk/gp-conference

emedica life after cct course23 June, 30 June, 14 July

london, Birmingham, manchester

What to expect as a newly qualified GP

www.emedica.co.uk

Practice management seminar 5 september Bedford seminar on risk management and complaints

www.mps.org.uk/gp

mPs ooh and Unscheduled Primary care conference 2012

20 september manchester explore the risks in this field www.mps.org.uk/conferences

update bringing you the news that affects your practice

Independent prescribers in england including nurses, midwives and pharmacists will now be able to prescribe controlled drugs such as morphine, diamorphine and

co-codamol under changes to misuse of Drugs regulations.nurses and pharmacists will also now be able to prescribe

controlled drugs in community pain clinics for patients with long-term conditions such as arthritis. they will also be able to mix a controlled drug with another medicine for patients who need urgent intravenous treatment for pain relief in a&e or palliative care settings.

chief nursing officer Professor Dame chris Beasley said: “these changes will help deliver faster and more effective care, making it easier for patients to get the medicines they

need, without compromising safety. enabling appropriately qualified nurses and pharmacists to prescribe and mix those controlled drugs they are competent to use, for example in palliative care, completes the changes made over recent years to ensure we make the best use of these highly trained professionals’ skills, for the benefit of patients.”

the changes affect around 20,000 nurses and midwives and 1,500 pharmacists qualified as ‘independent prescribers’ who will now be able to prescribe controlled drugs where it is clinically appropriate and within their professional competence.

Visit: www.dh.gov.ukhealth/2012/04/prescribingchange/

nurses and pharmacists to prescribe controlled drugs

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one to WAtch

all providers of health and adult social care, including providers of primary medical services as of next year, have to be registered with the care Quality commission (cQc) by 1 april 2013. the application form will be available from July 2012. Providers will be able to submit their form from september 2012. Providers will need to declare whether or not they are compliant with the 16 essential standards related to quality and safety of care. once registered, the cQc will monitor whether providers continue to meet essential standards. links to the cQc resources mPs has produced can be found on page 7.

cAmPAign

large shops in england are now required by law to cover up all tobacco products on their shelves. the same will apply to small shops from 2015. evidence shows that open displays of tobacco in shops can encourage young people to take up smoking. this is one of the initiatives in the Healthy lives, Healthy People: a tobacco control Plan for england campaign. the campaign urges frontline health professionals to use the opportunity to “make every contact count”, to help people stop smoking and to direct them to local stop smoking services. Visit: http://smokefree.nhs.uk/

legAl UPdAte

the nHs (Primary medical services) (miscellaneous amendments) regulations 2012 came into force on 30 april 2012. the new regulations amend the nHs (General medical services contracts) regulations 2004 and the nHs (Personal medical services agreements) regulations 2004. the regulations introduce the Patient choice scheme that enables patients to register with a participating practice in an area in which the patient does not reside or to visit a participating practice for a consultation without registering. the regulations go on to outline the procedure for practices who wish to close and reopen their lists to new patient registrations and updates the provisions relating to vaccines and immunisations. Visit: www.legislation.gov.uk/uksi/2012/970/pdfs/uksi_20120970_en.pdf

UsefUl links

nIce has launched its first smartphone app containing all its guidance in one place. nIce have dubbed this “the first in a series of proposed app developments from nIce, which will eventually cover medicines and prescribing information, nIce Pathways and other nIce products”. the app is free to download and is compatible with android smartphones, apple iPhones and iPod touch running Ios 4.3 and above. It can be downloaded from apple’s istore and the android market. Visit: http://www.nice.org.uk/newsroom/news/GuidanceAtAGlanceonYoursmartphone.jsp

in yoUR PRActice

error in one in 20 GP prescriptions

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a major study has found that while the vast majority of GP prescriptions are appropriate, one in 20 contains an error.

Investigating the Prevalence and Causes of Prescribing Errors in General Practice, which was commissioned by the Gmc, revealed that one in eight patients had mistakes in their prescriptions, with the elderly and the young the worst affected. the most common types of error found in the prescriptions were:

■ incomplete information on the prescription ■ dosage errors ■ incorrect timing of doses ■ failure to request monitoring.

the study looked at 15 general practices from three areas of england and analysed the records of 1,777 patients. the risk of prescribing mistakes increased according to the number of medicines a patient was taking (each additional medicine increased error risk by 16%), patient age (children and over-75s were twice as likely to have an error) and the type of medicine prescribed. In many cases, however, the report said mistakes were picked up and corrected by pharmacists.

researchers identified a number of contributing factors in prescribing errors including deficiencies in GP prescribing training, pressure and distractions at work, lack of robust systems for ensuring patients receive necessary blood tests and problems relating to GPs using computer systems – ie, overriding important drug interaction alerts.

lead researcher Professor tony avery 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.”

Dr clare Gerada, rcGP chair of council, said: “there are over one million patient consultations in general practice every day across the uK, and this report demonstrates that in 95% of cases GPs prescribe safely and effectively in the best interests of their patients.

“the report highlights issues around GP training, the majority of which we are already working to address. two weeks ago the rcGP successfully submitted its educational case for extended and enhanced training to the medical Programme Board of medical education england (mee), with the aim of broadening the experience of future GPs in dealing with the increasingly challenging and complex environment of general practice.

“the GP training curriculum, introduced by the rcGP in 2007, is also in the final phase of a three year revision which will shortly be submitted to the Gmc. In the current version of the curriculum, patient safety is the main objective of prescribing. In the revised version doctors will be required to demonstrate their competence in both prescribing and medicines management.”

UsefUl links

■ Gmc news – www.gmc-uk.org/news/13017.asp

■ mPs factsheet, Safe Prescribing – www.medicalprotection.org/uk/

factsheets/safeprescibing


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a poll commissioned by GP newspaper revealed that 42% of participating GPs believe they are

not ready for registration.1 From July this year the race begins for practices to register with the care Quality commission (cQc), the independent regulator of all health and adult social care in england. this registration must be completed by 1 april 2013 when new legislation will come into force requiring providers whose sole or main purpose is nHs primary medical services to register with the cQc.

this includes those providers of General medical services (Gms), Personal medical services (Pms) and alternative Provider medical services (aPms). regulations require practices to register as either an individual, a partnership or an organisation. as part of the process practices will also be required to adhere to a set of essential quality standards, which will be continuously monitored.

so what does this mean to you as a provider of primary medical services? You have got to register – there is no alternative! From July practices will receive an invitation from the cQc to begin the application process (registration). Practices will then be able to choose a date between september and December 2012 to submit their online application.

In the application practices will be asked to state whether or not they are compliant with the Essential Standards of Quality and Safety.2 If a practice is not compliant with a standard then an action plan must be submitted, detailing what the practice will do to become compliant and the date that this will be completed.

Warming up Before you start tackling the obstacles, there is some preparation work to be done. For example:

■ Decide if you are going to register as a partnership (the cQc expect most GP practices will register as this), organisation or individual (eg, single-handed practice).

■ confirm your location – the place where the regulated activities take place. If you have a branch surgery, which is managed by the main practice, then you will not have to register it as a separate location.

■ appoint two leads for the cQc registration process:– one is the overall lead, ie, the

‘registered manager’, who will have legal responsibilities (eg, GP partner)

– the other, the ’nominated individual’, will be the main contact for the cQc (eg, practice manager).

■ consider which regulated activities your practice is going to register for, eg:– treatment of disease, disorder and

injury– Diagnostic and screening procedures– surgical procedures (above and

beyond curettage, cautery and cryotherapy procedures. Practices who undertake the ‘minor surgery enhanced’ service may need to register this activity)

– maternity and midwifery services– Family planning services – only for

those practices who undertake insertion or removal of intrauterine contraception devices.

■ Identify which staff in the practice will need to have a crB check.

■ organise a cQc training session for all the staff.

on your marks – get set.... the applicationthe cQc will want to know that a provider has reviewed their evidence to determine whether they are compliant. mPs is aware that many practices are anxious about how they will comply with the requirements.

the key thing to remember is that the cQc will want evidence to demonstrate compliance; it is not enough to have policies and procedures in place. undertaking a clinical risk self assessment (crsa) will assist you by highlighting areas where you may not be fully compliant.

go!!! – scaling the top risks mPs has produced a guide to the cQc registration process, Signposting the CQC, which can be downloaded from the mPs website (see links below).

Below are risk tips for practices based on an analysis of mPs crsas, which revealed the most common risks present in practices.

1. communication the crsa research revealed that 99.4% of practices had risks relating to communication.

the risks identified relating to communication are split into two categories; internal communication (cQc outcome 6, Regulation 24) and communication with patients (cQc outcome 1, Regulation 17).

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The countdown to CQC registration has begun. Julie Wilson shares some tips to help practices jump through those tricky final hoops

6

Going for Gold

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A. internal communicationi. Practice meetings: ensure that the

minutes of key practice meetings are signed by the chairman, dated and reviewed for both accuracy and “matters arising” at the next meeting. It is possible that the cQc will regard the quality of minutes as an indicator of managerial standards generally within a practice.

ii. internal message system: It is essential to have an effective internal messaging protocol; eg, via an electronic message system. to negate the danger of messages/patient information being inadvertently lost, the use of Post-It® notes and pieces of paper should be discouraged.

iii. Primary healthcare team: ensure there are effective systems in place for communicating/liaising with district nurses, health visitors and other members of the multidisciplinary clinical team. ensure that all contacts from the out-of-hours service are reviewed by a clinician and action taken as applicable.

b. communication with patients i. Patient information: ensure that

there is an up-to-date practice leaflet and website that includes details of the practice services, opening times, etc. consider whether there is a need to publish the leaflet in other languages. consider whether the needs of visually and hearing impaired patients are being adequately met, eg, audio loops.

ii. text messaging: While the use of text messages can offer greater convenience and flexibility for patients and doctors, only send text messages to those patients where consent has been recorded for you to undertake this form of communication. mPs has produced a factsheet on text messaging patients – www.medicalprotection.org/uk/england-factsheets/communicating-with-patients-by-text-message.

iii. involving patients: Practices must be able to demonstrate that patients are encouraged to be involved in how the service is run. this can be through patient participation groups/forums, patient surveys and the practice newsletter/website. this is a core area identified by the cQc and one where they anticipate most practices will not achieve the standard.

2. confidentiality of the practices, 98.7% had risks relating to communication. ensuring that a service user’s privacy and dignity is upheld is an important element of cQc outcome 1, Regulation 17; therefore practices may want to consider their approach to confidentiality.i. Practice layout: looking at the

layout at reception, perhaps repositioning the computer screen or moving the telephones away from the front desk, would help to reduce the risk of breaching confidentiality.

ii. staff confidentiality clause: many of the staff live in the area where they work, so it is very important to reinforce the need to keep this information confidential. It is also not appropriate for staff to discuss the practice or staff members on social networking sites, eg, Facebook. a clause could be included in a staff member’s contract. It is important that all members of staff are trained in confidentiality issues and that the message is regularly reinforced.

3. Prescribingof the practices, 87.8% had risks relating to prescribing. common specific examples include wrong dose, inappropriate medication and failure to monitor for toxicity and side effects. to demonstrate compliance with cQc outcome 9, Regulation 13 management of medicines, you will need to demonstrate that all staff have been trained in the repeat prescribing process and that they adhere to the protocol.

Best practice indicates that medication added to the prescription list should be done by the GP. If medication is added to the computer or changed by administration staff, it must be closely checked by the doctor afterwards; considerable care needs to be taken to ensure that all the details are correct and that it has been added to the correct patient record. the doctor has responsibility for the prescriptions he/she signs.

4. Record keepingof the practices, 87.2% had risks relating to record keeping. With cQc outcome 21, Regulation 20, the cQc will be looking to see that the service users are protected against the risks of unsafe and inappropriate care and treatment arising from the lack of proper information about them. contemporaneous records are essential for good quality care and are needed if a complaint or claim is made.

common risks: i. letters scanned onto computer

occasionally saved into wrong recordii. telephone advice and home visits not

always recordediii. no summarising protocol. this is an

important task and should ideally be undertaken by a person with a clinical background.

MPS Educational Services deliver medical records workshops for GPs, offered as a benefit of membership. For further details please see the website below – www.medicalprotection.org/uk/education-and-events/medical-records-for-gps

5. staff trainingIt seems very likely that the cQc will consider a well-documented programme of mandatory training to be a basic requirement for practices. to demonstrate compliance with cQc outcome 14, Regulation 23, practices will need to demonstrate that staff are competent to carry out their work and are properly trained, supervised and appraised.

Practices may wish to keep a simple spreadsheet record of staff training – where the cells in the spreadsheet contain the date on which each named employee last had training in a particular mandatory topic.

the finishing lineso don’t be downhearted; overcome the cQc hurdles with a winning mentality and aim for Gold. Prepare, warm up, go and win.

Julie is speaking about these issues in more depth at the MPS General Practice Conference 2012.

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mPs cQc resources

MPS has created a booklet, Signposting the CQC: Understanding Your New Registration – www.medicalprotection.org/uk/booklets/signposting-the-cqc. It is also available to download as an app on iPad, iPhone, iPod Touch or Android devices from the website above. The CQC website for GPs is now live. Access it here www.cqc.org.uk/register – it includes an introductory video from Professor David Haslam.

AÊ pollÊ commissionedÊ byÊ GP newspaperÊ revealedÊ thatÊ 42%Ê ofÊparticipatingÊ GPsÊ believeÊ theyÊ areÊ notÊ readyÊ forÊ registration

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While many practices are gearing up for registration, some practices have been working

hard to demonstrate compliance with the cQc’s requirements for many months. Here is a profile of st Georges medical centre, who have developed a fantastic computer recording system to assist with their registration. We hear from practice manager Doreen Phoenix and finance administrator Pam leonard, the brainchild of this innovative system.

doreen Phoenix, practice manager:“about a year ago we began preparing for cQc registration – we took Pam leonard, our finance administrator, away from her normal job to organise it all. all 27 practices in our consortium pay for the use of First Practice management protocols and templates, so that we are all singing from the same hymn sheet. It was one of these templates that Pam used as a base to develop our cQc registration system. Pam is a real whizz – she has created an excel spreadsheet containing all the cQc’s Essential Standards, every cQc outcome and embedded our evidence behind each one.

“the key is having evidence embedded in any data you collect. When we began, we had already pooled a lot of the information together for information governance, so for the cQc registration it was simply pulling the evidence into another area.

“my advice to practices is the sooner you get started the better – you have to comply with the 16 regulations. I was chatting to a practice manager from a practice in liverpool, who told me that their ccG had instructed them not to do anything with the cQc registration for now. I would be worried if I hadn’t started yet.

“at a cQc roadshow the registration process was downplayed, not such a

big thing. I would disagree; if practices don’t start pooling their protocols etc, it will be an even bigger task for them to finish by the deadline.

“We haven’t struggled with the overhaul protocols, as they are visible and accessible. It is the timescales that are worrying us and the other practices in our consortium. When you have registered you have 28 days to get the registration through and submit all your evidence – there is no leeway.

“looking ahead the hardest part for me will be making sure that all the staff are trained and constantly aware. If the cQc visit and speak to staff and you’ve got no evidence of their training that is a big thing. the biggest thing for staff is time and knowing about all these policies. the tricky thing with this will be allocating time to train. Increasingly we are using e-learning software to train our staff on health and safety, manual handling, fire safety, etc; doing it this way means staff can fit it around their day jobs.”

Pam leonard, finance administrator:“I was updating the protocols and procedures library, when Doreen suggested I look at the cQc information. I felt I could organise it in a more accessible format. each cQc standard is defined on the front page of the spreadsheet; this is then followed by the cQc outcomes – each

one contains subsections that show how the evidence has been embedded, eg, who is doing it, who is responsible for it, what stage it is at and what training is required.

“as you click through each outcome, the protocols that the practice has in place are easily accessible. under these headings, a traffic light system is in operation – you can see who is dealing with each one, whether it is a work in progress, has been completed, or further training needed. this allows you to see at a glance where you are with each one, who has been trained and who hasn’t. once this has been completed there is a button where you can print a certificate off to demonstrate that certain outcomes have been achieved.

“so basically this is an easy-to-use spreadsheet containing 205 documents based around the cQc’s Essential Standards, where the evidence is embedded. some of the protocols will be duplicated under different outcomes, but that shows how well the practice is prepared for registration.

“at the moment we are working our way through our protocols and adding to them as we go along. I will continue to do this alongside my day job up to and after registration.”

For more information about what St Georges Medical Centre have done, please contact Doreen on the practice telephone number: 0151 6302080 or visit www.stgeorgesmedicalcentre.com.

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Practice: St Georges Medical CentreWhere: WallaseyPatients: 9,800commissioning: Ophthalmology, phlebotomy, minor operationsWebsite: www.stgeorgesmedicalcentre.com

RefeRences

1. soteriou m, GPs face a year of turmoil in 2012, GP (15 may 2012)

2 cQc, Essential Standards of Quality and Safety (2010) – http://www.cqc.org.uk/standards

How are practices tackling CQC registration? Here is a profile of St Georges Medical Centre

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Dr c had been on a short period of leave and when she returned she reviewed the post that had

been received in her absence. In and amongst the assorted hospital correspondence and Pma requests, Dr c came across a letter from the DVla seeking updated medical information in relation to a mr J. attached to the request was a consent form recently signed by mr J, providing his authority for Dr c to disclose any relevant information to the DVla. It indicated that he did not wish to have sight of the report before it was submitted to the DVla.

Dr c had been mr J’s GP for several years and had assisted him primarily in relation to his difficulties with alcohol dependency. as a consequence of mr J’s alcohol dependency, which was corroborated by abnormal blood markers, the DVla had revoked his licence for a period of one year, and this had led to mr J being dismissed from his job as a salesman of commercial air-conditioning units. unfortunately, this further compounded mr J’s difficulties with alcohol, which culminated in a recent hospital admission as a result of acute alcohol intoxication (which was, once more, corroborated by abnormal blood markers). the reason why the DVla were now seeking updated medical information was to consider whether or not it would be appropriate to reinstate mr J’s licence.

the request from the DVla was in the form of a questionnaire and Dr c completed it in an entirely factual and reasonable way. In response to a question asking if there was any recent evidence of alcohol misuse (including binge drinking), Dr c provided information in relation to the recent

hospital admission. Given that mr J had provided his consent to share relevant information with the DVla, and that he had not requested sight of the report before submission, Dr c submitted the completed questionnaire. on the basis of the information provided, the DVla determined that mr J’s licence would remain revoked until he could demonstrate a minimum period of controlled drinking (or abstinence) accompanied by the normalisation of the blood markers.

several weeks later, Dr c was served with a claim form, in which she was the named defendant in an action of defamation brought by mr J (acting as a litigant-in-person). the basis of the action was that the information was not true, it was provided without consent and that, as a consequence of the disclosure, the DVla declined to reinstate mr J’s licence. Dr c did not feel that her actions were open to legitimate criticism and was left unnerved.

Dr c contacted mPs and was assisted by a medicolegal adviser and an in-house solicitor. the solicitor went on the record with the court on Dr c’s behalf and made an application for the action to be struck out on the basis that the information provided was factually correct, provided with mr J’s consent and that it was a matter for the DVla to decide whether or not mr J was medically fit to drive.

the application for the action to be struck out was heard promptly by a county court judge who agreed that the claim had no basis and therefore struck out the action. Dr c was relieved that mPs were able to take over the correspondence and have the action struck out so promptly.

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Dr c had been on a short period of leave and when she returned she reviewed the post that had

been received in her absence. In and amongst the assorted hospital correspondence and Pma requests, ma requests, maDr c came across a letter from the DVlaseeking updated medical information in relation to a mr J. r J. r atata tached to the request was a consent form recently signed by mr J, providing his authority for Dr r J, providing his authority for Dr r c to disclose any relevant information to the DVlalal . It indicated that he did not wish to have sight of the report before it was submitted to the DVlalal .

Dr c had been mr J’s GP for several years and had assisted him primarily in relation to his difficulties with alcohol dependency. as a consequence of mr J’s alcohol dependency, which was corroborated by abnormal blood markers, the DVla had revoked his la had revoked his lalicence for a period of one year, and this had led to mr J being dismissed from his job as a salesman of commercial air-conditioning units. unfortunately, this further compounded mr J’s difficulties with alcohol, which culminated in a recent hospital admission as a result of acute alcohol intoxication (which was, once more, corroborated by abnormal blood markers). the reason why the DVla were now seeking updated la were now seeking updated lamedical information was to consider whether or not it would be appropriate to reinstate mr J’s licence.

the request from the DVla was in the la was in the laform of a questionnaire and Dr ccompleted it in an entirely factual and reasonable way. In response to a question asking if there was any recent evidence of alcohol misuse (including binge drinking), Dr c provided information in relation to the recent

hospital admission. Given that mr J had provided his consent to share relevant information with the DVla, and that he had not requested sight of the report before submission, Dr c submitted the completed questionnaire. on the basis of the information provided, the DVladetermined that mr J’s licence would remain revoked until he could demonstrate a minimum period of controlled drinking (or abstinence) accompanied by the normalisation of the blood markers.

several weeks later, Dr c was served with a claim form, in which she was the named defendant in an action of defamation brought by mr J (acting as a litigant-in-person). the basis of the action was that the information was not true, it was provided without consent and that, as a consequence of the disclosure, the DVla declined to la declined to lareinstate mr J’s licence. Dr c did not feel that her actions were open to legitimate criticism and was left unnerved.

Dr c contacted mPs and was assisted by a medicolegal adviser and an in-house solicitor. the solicitor went on the record with the court on Dr c’s behalf and made an application for the action to be struck out on the basis that the information provided was factually correct, provided with mr J’s consent and that it was a matter for the DVla la lato decide whether or not mr J was medically fit to drive.

the application for the action to be struck out was heard promptly by a county court judge who agreed that the claim had no basis and therefore struck out the action. Dr c was relieved that mPs were able to take over the correspondence and have the action struck out so promptly.

legal eye examples of cQc outcomes and the practice protocols that underscore each one

outcome 7, safeguarding children (28 protocols in this file)For example, complaints procedures, chaperone policy, carers’ registration, child health surveillance guidelines, health protection flow chart.

outcome 10, safety and suitability of premises(33 protocols in this file)For example, bomb scare handling, building hazards and information, CCTV, CCT access, cleaning rota, clinical waste management, disability protocol, maintenance logs, fire risk assessment, health and safety policy, infection control, inspection checklist, violence and aggression.

outcome 9, safety of medicines(26 documents in file)For example, controlled drugs, anaphylaxis statement, repeat prescribing policy, medicines management, and medication review.

outcome 2, consent(14 documents in file)For example, advance directives, chaperone policy, carers’ policy, confidentiality and consent protocols, disclosure of patient information, Mental Capacity Act, military priority, vulnerable adults.

Useful links

Practice xtra – the new practice reward package

Practice Xtra has been designed with the needs of practices in mind – the more doctors in your practice that are with MPS, the more benefits you can receive. There are two levels of Practice Xtra – Silver and Gold.

■ silver is intended for practices when approximately 50% of GP partners (minimum of two GPs) are MPS members

■ gold is intended for practices where approximately 80% of GPs (minimum of two GPs) are MPS members.

Depending on the level you are eligible for there are many extra benefits to help you meet the CQC requirements. These include a free CRSA, free risk management training and employment law and health and safety advice.

To find out how you can benefit from Practice Xtra visit www.mps.org.uk/gppractice

MPS Solicitor Mark JordanMark Jordan describes a case where a defamatory claim against a doctor was successfully a defamatory claim against a doctor was successfully struck out

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UsefUl links

■ Gmc publication, Confidentiality: Supplementary Guidance (paragraphs 1-8, Reporting Concerns About Patients to the DVLA) – www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp

■ DVla, At a Glance Guide to the Current Medical Standards of Fitness to Drive – www.dft.gov.uk/dvla/medical/ataglance.aspx


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the word ‘triage’ comes from the French word ‘trier’, which means ‘to sort’. telephone triage is when

a healthcare professional, usually a registered nurse, speaks by telephone to a patient and assesses the patient’s symptoms or health concerns. the nurse will then, in conjunction with the patient, devise a plan as to how the health concerns can be most appropriately addressed (this may include providing advice or arranging a face-to-face consultation with either the doctor or the nurse).

there is no doubt that telephone triage has revolutionised medicine and has benefited patients and practices. For patients it can be more convenient and provide easier access. For practices, these encounters can reduce inappropriate appointments, reduce anxiety and play a part in educating patients, empowering them to play a more active role in managing their health conditions.

However, alongside the benefits of telephone triage and with the changes in roles and responsibilities of nurses, the risks must be considered.

training and experiencenurses are trained to use their observational skills when assessing a patient. these sources of information are eliminated when assessing a patient over the telephone, so nurses must

rely more heavily on their own communication skills and clinical experience. Decision-making in telephone triage can be complex – the practitioner is relying on the patient’s understanding of their own condition and their ability to communicate the relevant information.

For GPs and practice managers, ensuring that nurses have the relevant experience to undertake this role is of paramount importance. the most common risk associated with telephone triage is miscommunication. Without being able to see or examine the patient, nurses may feel under pressure to make decisions too quickly. It is important that all nurses receive appropriate training on communication and listening skills prior to commencing this role.

It is also important that those nurses practise within their own limitations and competence.

nurses are professionally accountable to the nursing and midwifery council

(nmc), as well as being contractually accountable to their employer and to the law for their actions. the nmc code states: “as a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions” and “You must recognise and work within the limits of your competence.”1

supervision and auditalongside training, there should be provision made for nurses to undertake clinical supervision. It is good practice to offer those nurses who perform telephone triage the opportunity to be able to reflect on their assessments, focusing on what went well and what could be improved. there should also

be the opportunity for the nurse to discuss any particularly challenging calls with an experienced colleague.

some practices record all telephone consultations and these would certainly

As the demand for instant healthcare and ‘on the go’ medical advice escalates, more practices are introducing nurse telephone triage. Diane Baylisexplores the risks of nurses performing telephone triage

DecisionÊ makingÊ inÊ telephoneÊ triageÊ canÊ beÊ complexÊ ÐÊ ÊtheÊ practitionerÊ isÊ relyingÊ onÊ theÊ patientÕ sÊ understandingÊ ÊofÊ theirÊ ownÊ conditionÊ andÊ theirÊ abilityÊ toÊ communicateÊ ÊtheÊ relevantÊ information

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nurse telephone triage

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be of use in the event of any future complaints or issues. these recordings would constitute part of the medical record and so the same rules of confidentiality and storage apply as for the clinical patient notes. Patients must be informed that the calls are being recorded.

It is also important that calls are audited using an appropriate quality audit tool.

Protocolsthe use of written clinical protocols and agreed standards ensures that the nurses have a consistent approach to the management of common acute illnesses and outcomes. this will help to standardise the process with regards to data collection, planning, intervention and evaluation.

Protocols should include identifying ‘high risk’ callers, which may include:

■ elderly patients ■ Young children ■ repeat callers ■ Patients with multiple complaints or conditions

■ Poor historians ■ Patients whose first language is not english

■ Patients with hearing or speech difficulties.

the nIce guidance entitled Feverish Illness in Children: Assessment and Initial Management in Children Younger Than Five Years is particularly helpful in relation to the assessment of young children.2

many GP out-of-hours organisations use a computer decision support software tool. this supports nurses’

clinical decision making, promotes safety and ensures consistency in triage outcomes. considering the use of such a decision support tool would be beneficial for ‘in-hours’ telephone triage.

structured approach to assessmentWhen undertaking telephone assessments it is important to adopt a structured approach. conducting a structured exploration of the current problem, medical history and usual health status will enable nurses to provide advice on immediate treatment, referral or other action needed. clarify and confirm the patient’s understanding, agreement and responsibilities for any action that is taken.

safety nettingWhen a plan of care has been agreed, the nurse should explain the healthcare advice required, the natural history of the condition and any worsening signs to look out for and encourage the patient to call back if they have any further concerns. confirm that the agreed action is understood by the patient or caller.

documentationDetailed documentation of the telephone assessment is vital. It is important that the medical records include enough detail to justify the proposed management and to demonstrate that appropriate management of the patient’s problem could take place without the need for a face-to-face consultation.

summaryFace-to-face consultations or appointments with a doctor come at a high cost. It is important that the introduction of nurse triage is not introduced as a result of an effort purely to save money. When introduced after sufficient input into the above suggestions, it can be a safe, effective and valuable resource for the GP surgery.

Diane Baylis is clinical risk manager for MPS Educational Services.

toP tiPs foR nURses PeRfoRming telePhone tRiAge

■ Ensure nurses have the relevant qualifications and experience

■ Ensure they receive training to focus on communication skills

■ Provide supervision and audit calls

■ Develop and agree clinical protocols

■ Consider the use of a decision support software tool

■ Adopt a structured approach to telephone assessment

■ Ensure that safety-netting advice is given

■ Ensure detailed documentation of calls

■ Consider recording telephone calls

■ Ensure that nurses undertaking telephone triage have adequate indemnity arrangements in place.

RefeRences

1. nursing and midwifery council, The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (2008) – www.nmc-uk.org/Publications/standards/the-code/introduction/

2. nIce, Feverish Illness in Children: Assessment and Initial Management in Children Younger Than Five Years (2007) – http://publications.nice.org.uk/feverish-illness-in-children-cg47

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ManyÊ GPÊ out-of-hoursÊ organisationsÊ useÊ ÊaÊ computerÊ decisionÊ supportÊ softwareÊtool.Ê ThisÊ supportsÊ theÊ nursesÕÊ clinicalÊdecisionÊ making,Ê promotesÊ safetyÊ andÊensuresÊ consistencyÊ inÊ triageÊ outcomes

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the medicAl PRotection society

33 cavendish square london, W1G 0Ps united Kingdom

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the medical Protection society is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world.

mPs is not an insurance company. all the benefits of membership of mPs are discretionary as set out in the memorandum and articles of association.

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