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GPs defending patient complaints to be asked which guidelines they followed

GPs undergoing investigation by the Parliamentary and Health Service Ombudsman (PHSO) due to patient complaints will be asked which clinical guidelines they followed when making relevant decisions.

The change to the complaints investigation process, which has come into force this month, was implemented after a court ruling in a recent GP appeal case noted that the ombudsman’s standard for judging quality of care was ‘incoherent’.

But GP leaders questioned the new process, arguing that doctors need to be able to exercise 'professional judgement' when treating patients.

The updated Ombudsman’s Clinical Standard says the PHSO 'will ask the clinician or organisation complained about to tell us what, if any, standards or guidance they based their practice on, whether they followed them or departed from them in the situation complained about and why'.

It says: 'If there is a relevant standard or guidance and the clinical decisions, actions and judgements do not appear to have been in line with it, we will consider what evidence there may be to explain this.'

It adds that in deciding 'whether there has been good clinical care and treatment' the ombudsman 'will consider the explanations of those complained about and balance them against the relevant standards or guidance'.

Where there is 'no established standards or guidance', the PHSO will expect a 'rationale or justification for the care or treatment provided'.

In the foreword to the new standard, the PHSO said: 'When we look at a case, we begin our scrutiny of the health service that has been complained about with the expectation that good clinical care and treatment can be demonstrated by reference to standards or guidance.

'Good care and treatment will incorporate professional and health service standards and guidance and may incorporate the most up-to-date scientific evidence, for example, regarding the effectiveness of treatments.'

The PHSO argued the new standard would make the judging process 'more transparent'.

A spokesperson said: 'Our new clinical standard gives greater clarity and predictability to how we consider the appropriateness of NHS clinical care and treatment in England. 

'This will offer those complained about an earlier and clearer opportunity to explain how they reached decisions about care and treatment, and make our approach more transparent for the people who use our service.'

But BMA GP Committee chair Dr Richard Vautrey said: ‘GPs treat their patients as clinically appropriate, based on the best evidence, taking into account local and national guidelines.

'However consultations are often complex and patients require a holistic approach with a good degree of professional judgement required to deliver the most appropriate outcome.'

He added that the BMA 'will be seeking a meeting with the Ombudsman to talk about the implications of this statement for GPs to ensure they fully understand the challenges GPs face in their day-to-day care of patients'.

The news comes as the role of clinical guidelines has been a topic of debate for GPs and policymakers, with NICE previously having said their clinical advice is 'guidelines not tramlines'.

The Ombudsman’s Clinical Standard

  1. When we are considering complaints about clinical care and treatment we consider whether there has been 'good clinical care and treatment'. We aim to establish what would have been good clinical care and treatment in the situation complained about and to decide whether the care and treatment complained about fell short of that.
  2. We will seek to establish what constituted good clinical care and treatment on the facts of the case by reference to a range of material, including relevant standards or guidance, the accounts of the complainant and the clinician or organisation complained about and any other relevant records and information.
  3. Relevant standards or guidance we may consider include NICE guidance, clinical pathways, professional regulators’ codes of practice and guidance, guidance from royal colleges, local protocols or policies, and published research including clinical text books or research reported in peer review journal articles.
  4. In deciding whether a standard or guidance was relevant in the situation complained about we will consider factors such as whether it was in place at the time of the events complained about and whether it was applicable to the care and treatment the person received and to the setting in which the care and treatment took place.
  5. We will ask the clinician or organisation complained about to tell us what if any standards or guidance they based their practice on, whether they followed them or departed from them in the situation complained about and why. If there is a relevant standard or guidance and the clinical decisions, actions and judgements do not appear to have been in line with it, we will consider what evidence there may be to explain this. We will reach a decision about whether there has been good clinical care and treatment. In doing so we will consider the explanations of those complained about and balance them against the relevant standards or guidance.
  6. We will also consider the ‘Principles of Good Administration’ insofar as they apply to the clinical context.

Source: The Ombudsman’s Clinical Standard

Readers' comments (53)

  • Rogue1

    Ok, so give me 1/2 hour appointments. That way I can dig out and correctly reference every single decision I make in a day! What an absolute farce, we act in the patients best interest at every contact, and things are compromised because we take a holistic approach not simply following a guideline. On that point they are guidelines not required treatments, there is a difference they seem to fail to grasp!

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  • So we are expected to follow 'guidelines' in the ten minutes we have for a consultation.

    For every condition there are a plethora of guidelines, some conflicting. Also patients usually have more than one condition. They may be presenting with a symptom rather than a condition.

    The NHS are paying for a trabant but judge us as if they had purchased a Rolls Royce. Glad I am leaving early.

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  • National Hopeless Service

    And they wonder why there is a recruitment crisis......

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  • Guidelines? Or Protocols? Guidelines aren’t to be followed , ther are there as a guide to options, to be consulted as a support to clinical decision-making. Here comes the danger so many have spoken of with over-reliance on ‘guidelines’ and their institutionalisation- the workers took becomes the stick with which to beat them...

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  • So, lets look at cancer guideline.

    There is no longer any reference to timescale on change of bowel habit. We currently exercise clinical judgement and tell pt not to worry about a week's Hx of constipation.

    Under above ruling I can't produce evidence to say why I've "deviated" from NICE guidnce. So I can happily refer every Pt I see and flood the fast track clinic.

    Is this what we want?

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  • ‘Gut feeling’ executed. ‘Here goes neighbourhood!’

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  • Because common sense is not enough, I guess !

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  • What next, know how Promethius felt, getting his liver pecked out each day only to have it grow back . Just those with no clue of the job, deciding the parameters by which we should be judged. If it was so simple that a guideline would always suffice, no need for intelligent free thinking professionals, might as well use an app.....

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  • Quoting guidelines in 10 minute appointments?

    So glad I left GP training!

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  • Scottish GP correct- the sentiment that GP's are useless tossers and need to be babysat is rife and its about time we played them at their own game- if all GP's decided to only follow guidelines for a week we would soon be getting begged to use our valuable but highly underrated clinical acumen skills again

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  • how about we all agree a month of following guidelines say in october and get the entire profession to do this and swamp the hospitals. I feel like a bit of industrial action......

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  • You don't need a doctor to follow guidelines. Any idiot can use a flow chart.

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  • Another heart-sinking pronouncement.
    They will miss us when general practice is gone, by which time it will be too late

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  • My belief is it is all about preparing the profession for AI. Govt wants health care to be like painting by hundreds of numbers, but they keep changing and frequently conflict. Guidelines for multiple diseases are almost non-existent. No one will choose medicine as a career anymore. Healthcare could be delivered this way, but as has been said above, will require at least 30 minutes per condition per consult

    The Govt have not thought this through. Come on Sarah, speak up.

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  • I once had a complaint against me when I did not follow a guideline. The ombudsman upheld the complaint, but then said since then the guidelines had changed and I was in line with the current guidelines. The reason I did not follow the guideline at the time is because I thought it was inappropriate. The guidelines then change to support my action. What a world.

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  • Jones the Tie

    oooh does HMG realize what would happen if GPs decided to work to these 'guidelines' for every problem presented? that would take at least 30mins plus for an average appointment. How about we say 'yes that's fine but now I can only see 15 patients MAXIMUM a day and then we're full and you'll have to go elsewhere. This is another example of pen-pushers and politicos having absolutely NO EFFING IDEA how efficient and safe the vast qty of GP appointments are and how we hold OURSELVES to high standards and try to do the best we can with what we have. Give me an hour with each patient and no reams of paper work and I'll follow every guideline you want but the outcomes and safety won't be any better for the population they'll be a damned sight worse as the laws of un-intended consequences quickly kick in. Where is the safety data for any 'guideline ' anyway. nobody seems to question that and as far as I am concerned a lot of guidelines are not evidence based but 'consensus' based which basically means folk who don't actually do the job sat around a table deciding what the folk that do should do...ahhghghhhhhh. I should be judged by the standards of my peers ie OTHER GPs who do the job NOT a bunch of various folk who are usually secondary care or industry folk sat around a table so until we get 'guidelines' produced by jobbing GPs whatever standard guidelines the ombudsman wants will be irrelevant oooh and by the way us coal face GPs usually haven't got the time to sit around tables coming up with guidelines as we are actually at the effing coal face trying to keep the NHS Titanic from sinking...there I've said it

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  • One of the most difficult areas is acting on blood results.

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  • This is why for some time I have urged everyone to talk about 'guidelines' (which are intended to be more fuzzy and therefore can more easily be appropriately ignored) and 'protocols' which have to be obeyed.
    The PHSO doesn't seem yet to have twigged that a profession is by definition an occupation that cannot be defined by rigid protocols or guidelines, nor can it be assessed by simple targets: any attempt to do either of these merely acts to destroy that profession and so its workers become mere functionaries. Perhaps that's the idea?
    However, medicine is currently impossible to reduce to simple guidelines and rules (and in any case, guidelines and rules are NOT what AI is about). In AI even the creators of the robots often don't know how/why the robot is working as it does. I can see the argument that managers and politicians are trying to replace GPs with robots -- I just know that this isn't going to happen in medicine in a global way (i.e. as opposed to a very specialised function) any time soon.

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  • Dear All,
    The guideline i follow is the one espoused by the Chairman of NICE, Sir Michael Rawlins, in October 2012;

    "The institute’s recommendations are advisory for GPs and sometimes almost aspirational in nature, writes NICE chair Sir Michael Rawlins

    There appears to be confusion about the circumstances in which it is obligatory for GPs to follow NICE guidance. The quick answer is ‘never’.

    Then there are clinical guidelines, which provide GPs and other clinical staff with guidance on the management of specific clinical conditions, for instance, for antenatal care, breast cancer and schizophrenia. These guidelines are very unusual in taking account of both cost effectiveness as well as clinical effectiveness.

    There is no expectation, however, that all patients with a particular condition will be treated according to the provisions of NICE guidelines, for two reasons.

    First, it is impossible to define an appropriate pathway of care for every encounter between a doctor and a patient. Some patients, for example, are intolerant of particular medicines even though – at a population level – they provide substantial benefit.


    Second, the provision of care according to NICE guidelines may require infrastructure changes that take time to accomplish. NICE’s guideline on depression, for example, proposed much wider use of cognitive behavioural therapy (CBT) than was currently available. Substantial investment in clinical psychology has now put CBT within the reach of most patients who need it.


    So NICE’s guidance is never clinically mandatory, but is accompanied by the following statement: ‘This guidance represents the views of NICE and was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgment. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and/or guardian or carer.’ (And we mean it!)
    Rgeards
    Paul C

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  • NICE should be closed and it's budget restored to primary care where the money can be put to work. The whole guidelines thing needs a massive rethink. They are hugely complex, almost impossible to follow, rarely relevant to the complexity of real world patients, they increase our risk of complaints and litigation, and seem mainly to benefit drug companies and people who sell medical stuff. Overall I see very little benefit here, except for the rich and powerful.

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