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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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  • Guide lines. Are guide lines ‘not a legal requirement.
    Guide lines don’t come to my mind when i consult patients patients and I will not change any thing,
    I know what to do in most situation

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  • David Banner

    “The pirates’s code is what you would call....”guidelines”...than actual “rules”. Welcome aboard The Black Pearl, Miss Turner!!”
    We are governed by the likes of Barbossa and Jack Sparrow, who would sell us down the the river for a doubloon in a heartbeat.

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  • I think people are getting overly worked up about this. I am up to date on NICE, SIGN and local guidance and generally follow the principals. It looks like you will be able to indicate which guidance you generally followed and why you deviated from that guidance then they will judge if that is appropriate.
    Surely that is at least the same as before. The only difference is that you will be able to elect which guidance was the starting point. For example if your local CCG guidance is much more restrictive than NICE guidance, you can say that is your starting point rather than NICE. You are then still allowed to explain why your practice differed from that - but if our practice does differ from the norm, we should be expected to justify that.

    I think having the opportunity to say which guidance is the starting point is certainly a step forward.

    I think most of us have seen instances where clinicians have followed one guidance, then had a complaint because the patient says we did not follow guidance from different (often slightly outdated or dodgy) set of guidance. This issue will suddenly no longer be a problem.

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  • AlanAlmond

    It’s no longer safe to practice as a GP in the U.K. The country as gone nuts and lost its way. I’ve said it a hundred times already, I can’t do this any more. Herein lies the insanity of guidelines , who’s sole purpose has become satisfying the needs of the legal profession. Guidance is guidance..not law. The law jas become a self serving system, it drains resources from the sick and is an ever increasing burden on medical practice. You have got to be mad to feel safe working in healthcare in the U.K. the complexity of human sickness can not be simply distilled into arbitrary sets of rules , to be followed slavishly like an automaton without acknowledgement of human frailty emotion and thought. There are too many guidelines and far far too many self important lawyers. It’s too much. If people get sick , let them cure themselves , they can google the guidelines and treat themselves . Screw the idiots in Great Britain, they don’t deserve a Drs help.

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  • AlanAlmond

    It’s like treating people with a gun to your head, don’t screw up or you’ll be shot and eaten by wolves

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  • This reminds me of the eminent professor of paediatrics in the 1980s who solemnly announced in the BMJ that all children with a temperature exceeding 39C should be routinely admitted for a lumbar puncture. As we all know at the sharp end, this would reduce the hospitals to chaos in about 48 hours flat. If we are to have guidelines (?tramlines) they surely have to be developed by people who actually know what they are talking about, not by some academics in their ivory towers.

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  • Not so long ago the practise where I work had a complaint made which ended up with the Health Service Ombudstw~t sticking the oar in. Without going into too many specifics, the complaint related to alleged piss-poor practise on my part after a diagnosis made in secondary care of anti-convulsant toxicity without a corresponding blood-level of the drug in question having been made. The complaint was dismissed as a direct consequence of me consciously ignoring "The Guidelines" and checking a serum level of this drug after a dose-reduction had been instituted by me for what I regarded (and still do) as valid reasons.Undoubtedly I would not have been able to defend my practise if I had slavishly followed the guidelines.

    The work we do is complex and nuanced; one would have thought that those who make the rules would know this. Instead we have an ungrateful entitled populace, an NHS run down to a point which is beyond salvage and still we continue to serve. My advice is get debt-free and give em all 2 fingers as you walk on into the distance.

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  • surely we are to blame for foreseeing all this, and where we have reached with allowing those who sit in ivory towers to tell us do to impossible things in 10 minutes!

    Question is do we have insight to believe that we have gotten to where we are because we have passively allowed to happen to us?

    The first stage to remediation is insight and acceptance.

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  • Ivan Benett

    What a surprise that so many comments are negative to the use of guidelines. Of course they are 'only' guidelines, but they are also the basis of Evidence Based Medicine.
    I don't think it is unreasonable to ask people which guidelines we follow in any given clinical situation.
    HOWEVER, I have often expressed the limitations of guidelines and evidence based medicine. There are often good reasons for deviating from guidelines, but if we do, we should be able to justify why we did so. I think it is reasonable to ask this too.
    For many decisions, of course, there are no guidelines. In any case we should be able to justify our decisions by demonstrating the balance of benefit against risk, and taking account of the individuals wishes against the effect on others (affordability, cost, opportunity costs and harm).
    We need not be defensive about this move, but welcome the opportunity to explain why we made the decision we did. It might surprise our accusers of the depth of complexity of clinical decision making.
    We are also in a stronger position if we have involved the patient and carers in the decision making if appropriate. Complex decisions can be shared with colleagues and peers to show that we acted reasonably.

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  • in reply to Ivan Bennet the 'retrospectroscope' is always brought out when there is a complaint. This puts all the complex issues into a simplistic framework that has little to do with working in an overstretched underfunded service. for instance this hacking cough that has been doing the rounds. I have seen hundreds of patients coughing for more than 3 weeks yet did not xray any as I knew it was the cough. however if one later was shown to be Ca lung I have not followed guidance and in that case i am at fault. I am damned if I do and damned if I don't.

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  • "I don't think it is unreasonable to ask people which guidelines we follow in any given clinical situation." and therein lies the problem... Most clinical situations don't fit the patterns given buy guidelines. Those that do, often have conflicting issues like frailty that mean following them can do harm or is simply against the patient wishes. I'm not suggesting we don't practice evidence based medicine, that way lies madness but having to justify every decision to someone who doesn't work at the coalface or a smarmy lawyer sticks in the craw. Has anyone ever tallied up the opportunity cost of all these so-called guidelines in terms of complaint handling, litigation, compliance time and wasted resources? I suspect not.

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  • Did once ask a question of NICE re DVT Diagnosis

    If see patient Wells 2, D Dimer +ve but scan -ve what do you do during the week while waiting for a scan?

    To thick old me DVT probable/possible but not found it yet.

    Answer from NICE; we don't specifically advocate interval anti-coagulation during that week but expect clinical judgement to be used.

    So in reality may anticoagulated someone unnecessarily or possibly have a chat with the coroner if they go onto have PE

    Thanks a bunch, guidelines are as useful as the person who applies them and in this case PHSO are worse than useless

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  • Why on earth would anyone want to be a GP in the current climate?!

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  • Guidelines have been followed which were later shown to have been wrong and which caused harm. Beware expert's!

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  • Why can’t they simply stick with applying the Bolam principle? Is far more likely to take into account the pragmatism of real life general practice.

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  • It's guidance. Not a protocol. Have we not learnt anything? This will only increase referrals and investigations.

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  • doctordog.

    What worries me more is whos guidelines we follow.
    NICE often differs from other learned organisation guidelines eg BTS, RCOG, etc.

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  • Bob Hodges

    Looked at scientifically, even a hypothetically perfect guideline (impossible to achieve) will only apply to 95% of the patients 95% percent of the time.

    Therefore if you're NOT going off-piste at least one patient in 10, you're not being a GP, you're being a protocol monkey.

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  • Between CQC, NICE, GMC, the Ombudsman, the Law courts and Gross negligence manslaughter, do you want to be a doctor,let alone a GP in the UK.
    We are mad to work here.
    For example Dr BG was condemned for ' ignoring needless deterioration/decline', before transfer to general ward 28 from CAU by another clinician at 7 pm.
    Considering Jack was unresponsive on admission, if he had so declined he would be moribund. So, why was he transferred to a general ward, how did the ward accept such a dying child, why did the mother want to give regular medication to an unconscious child, and why is the clinician who transferred this child in this parlous state, not in court, only BG ?
    Fact is , Jack was bouncing about and well and fit for transfer.
    So, Dr BG's conviction for ' ignoring obvious deterioration' is not understandable,when Jack improved under her care in CAU and deteriorated after ACEI in ward 28 ?
    This is the risk you run if you work in the UK.

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  • "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"

    in other words we will find somewhere in the world anything we need to screw you, however obscure, however irrelevant.

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  • Ivan, your a better man than me if you can name all the guidelines on all the conditions.

    How I work is that I read the guidelines when I am introduced to them, perhaps at an educational half day, or an article in the BMJ or Pulse. What ever sticks is what I use when I see that patient in my allotted ten minute slot.

    To suggest that we all can all be up to date with the latest guideline for everything suggests a degree of perfection that we can aspire to, but sadly are unlikely to meet, due to being human, and not having the resources that we need for a perfect consultation. Perhaps you are more perfect than I.

    The threat, of course, is that they will find a more up to date guideline and crucify us with it.

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  • Based on my conversations with locuming junior doctors I would highly recommend GPs to think about leaving the UK.

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  • Those on the right side of the age spectrum are already leaving in droves and those on the other end are retiring early that says it all. The ones in the middle are in the fix to face the Rot. I can not understand what is the obsession with the doctors that the whole country is hell bent to destroy it with out realising that at the end of the day the demise of the NHS is to the detriment of all. Young intelegent and those with aspirations are catching the plane for a respectable job elsewhere.

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  • Best ever Guidelines that have stood the test of time
    HIPPOCRATES (born 2,478 years ago)
    1. Walking is your best friend (30 minutes walking lowers all risks)
    2. Know what person the disease has rather what disease the person has (treat patients as individuals)
    3. Let food be your medicine and not your killer (natural v processed food)
    4. Everything in moderation (obesity)
    5. To do nothing is also a good medicine (Time has a place as a diagnostic tool)
    6. The natural way is often the best way to treat (medicines extracted from nature sources)
    7. Treat the cause of an illness, not just the symptoms (patients on medication for life)
    8. Do not administer harmful medication (side-effects death toll is zooming)
    9. Keep a healthy colon (probiotics)
    10. See a r e a l doctor (comments welcome)




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  • The problem with an approach that says 'follow the guideline' is that it assumes the diagnosis has been made (or there is strong evidence to suggest a diagnosis). In reality GPs deal with often vague and non-specific presentations which need the diagnosis to be narrowed down before referring to the guideline. Many complaints are due to 'delayed' or 'wrong' initial diagnoses precisely due to the uncertain nature of our job.

    As far as whether guidelines are a good or bad thing; as someone who has contributed to 4 NICE guidelines I feel they are more good than bad. (I would say that!) They do vary in quality and fit to general practice but they do show what the evidence suggests may be the better management options. As others have said, they are not protocols and the NICE induction process makes it clear that a sinificant minority of cases may not fit the guideline. The problem arises not from the guideline development process but the assumption by others (the ombudsman included) that they are 1) Compulsory 2) always appropriate 3) Should be followed blindly without deviation.

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  • Ivan Benett how many patients do you currently see? And what are your other current roles? I believe you opted out of seeing patients as your main job a long time ago didn't you? So don't be smug at me about guidelines or have you turned into one of these Dement(educat)ors yourself now? Appraiser perhaps?

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  • AlanAlmond

    Don’t feed Ivan

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  • Guidelines are only guidelines or does the ombudsman not know. The erosion of professionalism and tailoring to the patient's needs continues. The UK has a toxic practice environment. No wonder all new doctors are leaving when they can.

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  • I’ve been in the coroners court when the coroner asked me to open a box file and read out a section of the guidelines for patients that deliberately self harm. Had I done everything on there ? The patient did not have borderline PD or depression.
    Problem with guidelines is that non experts don’t know how to apply them.

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  • A new Jeopardy!!

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