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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)

  • 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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