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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)

  • "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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