Belfast GP attacked at on-call centre
Delegation to other clinical staff makes good sense, but GPs need to comply with GMC guidance to ensure staff are suitably qualified and competent, says Dr Paul Colbrook
Teamwork and delegation are vital components of modern primary care. Done appropriately everyone benefits. GPs are able to focus on patients needing more specialised care, and patients get treatment and care in an efficient way.
With the latest contract, many practices may have changed or are changing their staff mix and adapting staff roles. As part of this process more care may be delegated to other professionals in the primary care team.
For example, nurses could take on additional responsibilities such as prescribing or minor surgical procedures. Or they may become partners.
The right skills
When delegating tasks to other team members, GPs must comply with GMC guidance and ensure the person to whom they delegate is suitably qualified and competent. In Good Medical Practice, the GMC says that when you delegate 'You must always pass on enough information about the patient and the treatment needed' (paragraph 46).
Nurses and other health care workers have a duty to ensure they provide a reasonable standard of care. Paragraph 6.2 of the Nursing and Midwifery Council (NMC) Code of Professional Conduct states: 'You must acknowledge the limits of your professional competence and only undertake practice and accept responsibilities for those activities in which you are competent'. This means nurses must only take on a task delegated to them if they are competent to do so.
If a GP asks a practice nurse to run a vaccination clinic, for instance, the GP must ensure the nurse is appropriately qualified and experienced and has access to appropriate information such as medical and vaccination records. In addition to ensuring that a particular vaccination is in the child's best interests, the nurse must make sure appropriate consent had been obtained from the parents, must ensure that this is documented and must ensure that the correct vaccination is administered in a safe manner. If the nurse has any concerns they must seek further advice.
Practice protocols define the standard of care to be provided. They can be an effective way of ensuring that staff are clear about their individual roles and responsibilities and can safeguard the interests of patients.
As it becomes more commonplace for patients to see a number of different health care professionals about one condition, having systems to ensure good communication is crucial. When working in teams the GMC says GPs must respect the skills and contribution of colleagues and communicate effectively with them (Paragraph 36 of Good Medical Practice). GPs must make sure that patients and colleagues understand the roles and responsibilities in the team and who is responsible for each aspect of the patient's care. The GMC also says that doctors should inform patients about how information is shared between those providing care, and that patients can object.
Where the buck stops
GPs often ask the Medical Defence Union who is responsible if something goes wrong in the patient's treatment when it has been delegated to a colleague. The GMC states that when delegating 'You will still be responsible for the overall management of the patient'.
This differs from referring a patient to another person, whereby the professional being referred to takes on some or all of the responsibility for the patient's care.
In law a GP can be held liable for the acts and omissions of an employee. The GP has vicarious liability.
If a patient believes they have been treated negligently by an employee they can choose to sue the doctor and/or the employee, for instance the practice nurse.
The Nursing and Midwifery Council advises nurses: 'You are personally accountable for your practice. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional' (Code of professional conduct, paragraph 1.3). GPs need to be satisfied that health care professionals, such as nurses, employed at the practice have adequate medical defence arrangements.
What to delegate
When making decisions about what to delegate the key consideration is whether doing so would be advantageous for patients. Many GPs delegate to a nurse tasks such as taking cervical smears, and running asthma clinics.
However, there are some tasks that may be inappropriate to delegate. Some GPs who carry out minor surgery ask whether it is appropriate to delegate the process of getting the patient's consent to a practice nurse. Paragraph 14 of the GMC's 'Seeking patients' consent: the ethical considerations' makes it clear that it is the GP's responsibility to give information and obtain consent if they are carrying out the procedure.
GPs may delegate the process of getting consent if it is not practicable for them to do it, provided delegation is to a person who is 'suitably trained and qualified, has sufficient knowledge of the proposed... treatment, and understands the risks involved', according to the GMC's guidance on seeking consent (paragraph 14).
The GP remains responsible for ensuring that proper consent has been obtained. For minor surgery however the practice nurse may not have sufficient knowledge about the planned procedure, the risks and benefits and possible alternatives to seek consent on the GP's behalf.
A GP saw a man who requested syringing of his right ear. On examination the GP suspected that the patient had impacted wax, and advised using oil to soften it, and asked the patient to see the nurse a week later to have the ear syringed.
The patient returned and had his ear syringed by a locum practice nurse. The patient later admitted he had felt pain and dizziness during the procedure. Two days later the patient said that his ear had been incompletely syringed and the same nurse repeated the procedure.
The patient returned to the surgery again a few days later complaining of a sore ear and was seen by the GP. The GP found that the eardrum had been perforated and prescribed antibiotics. It transpired that the nurse had not performed ear syringing for some 20 years.
Both the nurse and GP apologised to the man for the error. The patient brought a claim which was settled on behalf of the GP and the nurse.
The cases mentioned are fictitious, but based on cases from MDU files doctors with specific concerns are advised to contact their medical defence organisation for advice
Paul Colbrook is an MDU medicolegal adviser