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At the heart of general practice since 1960

GMC agrees that patients need local complaints portal

Is this private physiotherapist spinning things out for gain?

Three GPs share their approach to a practice dilemma

Case history

For some time you have been aware that a local private physiotherapist treats patients for an inordinate length of time before admitting defeat and sending problems to you.

You have often wondered how effective this physiotherapist's treatments are, or even whether money may be the motivation for protracted follow-up. You have nothing definite to go on but feel more comfortable recommending one of the other local practitioners when patients ask your advice.

Today you have Mrs C's X-ray report and blood tests which indicate metastatic bone disease in her spine, primary as yet unclear. She saw you last week for the first time and gave a story of intractable pain, keeping her awake at night. The physio had been treating her for spondylitis for two months before suggesting that she came to see you.

Dr Rodger Charlton

'This would be a useful case to raise at a practice meeting as a significant event'

This is a particularly difficult situation. One needs evidence to support the concerns you have about this. A good physiotherapist is one who can identify when they need to seek another opinion about a patient and so make a referral to a GP or specialist.

It is easy to conjecture that money is the motivating factor here, but one would need to be very sure that this is the case and collect documented evidence from more than one patient.

If the physiotherapist is working privately they may not have an NHS post and therefore they may not have an employer who can be made aware of what is happening. Also this practitioner may not be aware of their weaknesses professionally and therefore their learning needs.

This case would be a useful one to raise at a practice meeting, having recorded it as a significant event. Have other members of the team had any interactions with this physiotherapist?

Such a significant event review should try to ascertain what has happened and why. Is the physiotherapist aware of the situation and has this been a learning experience for them? What recommendations would the practice team make to prevent a similar event in the future?

While you wait for the outcome of the practice meeting, perhaps, a kindly rather than an officious letter pointing out the clinical circumstances of this patient would be appropriate. Say you would be very happy to see such a patient earlier to provide an opinion.

Also would it be possible to let you know in writing of any of your practice's patients being treated by the physiotherapist so that you could make contact if you thought there was any history or investigations they should be aware of prior to treatment.

Depending on the outcome of the practice meeting, if the situation persists, then I would need to carefully document any situations of concern and consider reporting this to the Chartered Society of Physiotherapy.

Rodger Charlton, a principal since 1987, is director of GP undergraduate medical education, Warwick Medical School

Dr Prashini Naidoo

'It is not my job to find evidence ­ just to make my concerns known'

The problem here is that I failed to act on my earlier suspicions, perhaps believing the sub-optimal management was due to genuine mistakes. But it now seems likely that my worst fears regarding the physiotherapist's underperformance have materialised.

Apart from choosing not to refer to the physiotherapist, my original plan had been not to take any futher action, perhaps for fear of doing harm by acting on unsubstantiated concerns.

But this fear was based on an incorrect assumption that I should act only if I have evidence of professional incompetence or misconduct. It is not my job to find evidence and make judgments. That is the task of the professional's licensing body.

It is my job to make my concerns known to such a body so that an investigation could be conducted if deemed appropriate. If shortcomings were identified, then appropriate remedial action should be taken.

Am I feeling guilty for not whistle-blowing? I need to examine whether my feelings of guilt are well-founded. To what extent has a two-month delay in making the diagnosis adversely impacted on Mrs C's quality of life and treatment options? What should I do now?

I would inform the UK Health Professionals Council. I would also discuss the incident at a practice significant event audit.

I would also discuss the merits of informing the Chartered Society of Physiotherapy and the National Patient Safety Agency.

The aim here is to develop and strengthen the national mechanism for reporting harm to patients, and to develop within the NHS a blame-free culture that can learn from its mistakes.

Dr Prashini Naidoo is a GP in Oxfordshire and has recently co-written 'Concepts and Answers for the MRCGP Oral Exam' ­ see http://www.scionpublishing.com

Dr Alex Williams

'While not wanting to mount a witch-hunt, alarm bells are ringing'

My first concern would be to the patient. I would want to obtain an accurate diagnosis and some idea of prognosis. A phone call and urgent referral to the local oncologist should help expedite this. Clearly some time needs to be spent with the patient explaining the findings and the suggested course of action.

When the dust has settled I would want to discuss early referral to our hospice care team and would want to involve the district nurses too.

It would be professional etiquette to inform the physio of your findings, but you would have to think about clinical competence and fitness to practise.

It may be necessary to review all recent cases in the practice, so clearly canvassing the opinion of your partners would be crucial.

We could take advice from the LMC and our own indemnity providers on the best course of action. Perhaps we could also contact the professional governing body of private physios.

The LMC could take a wider view and canvass the opinion of all local GPs in the physio's catchment area. While not wanting to mount a witch-hunt, the GMC duty of care and 'thou shall do no harm' are ringing in my ears.

The way forward will clearly be determined by the outcome of the information gathering. If it is an isolated incident then a meeting between representatives from the practice and the local physio may be appropriate (are they working for a larger provider that may have its own managers and supervisors?).

However, if it transpires this physio is making regular mistakes, then more rigorous action may need to be taken which may ultimately lead suspension and investigation.

Dr Alex Williams is a full-time GP in Exeter, a lead trainer in practice and an ex-hospital specialist in respiratory medicine

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