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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)

  • 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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