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At the heart of general practice since 1960

Partner accuses you of ignoring policy

At the practice meeting a partner says you have not observed policy on computer records. On receipt of a consultant's note advising an ACE inhibitor, the partner sent the patient a script and explained the side-effects. The patient rang the partner to say when he called at reception you gave him a handwritten script with the outpatient letter. Dr Melanie Wynne-Jones advises.

Is a practice meeting the right place to raise this?

Yes and no, depending on how it is raised and the intention behind it ­ public humiliation does not foster teamwork. You have, in fact, breached practice policy by failing to record the prescription in the computerised medical record, which could have serious consequences both for the patient and medicolegally. (The receptionist may also have breached practice policy by promising an immediate script or asking you to do it.)

In cases like this most doctors would first try to speak privately to the doctor and receptionist concerned. As a GP registrar your position is slightly different; it is reasonable for the partner to speak to you or your trainer.

Two doctors discussing such an episode will often agree that it is appropriate for it to be discussed by the whole partnership or practice team; it may not be an isolated incident and procedures may need review. However, the behaviour rather than the person should be criticised, and the discussion should be constructive, not a blame-game. Occasionally, meetings are used to ambush or intimidate other practice members; this is unacceptable and may constitute bullying.

Why do we need practice policies, protocols and procedures?

Practice policies are designed to be followed to the letter; they are different from guidelines which can be adjusted or ignored if

justified by circumstances. Policies:

ldefine the organisation's 'rules'

laddress and resolve differences of opinion

lreflect the practice's ethos and clinical/administrative standards

lshould be failsafe

lunderpin team-working, ensuring team members behave predictably

lensure/demonstrate that the practice meets external standards (for example, national service frameworks1, clinical governance2)

lensure/demonstrate that the practice meets legal requirements (for example, the Data Protection Act3)

lmay have disciplinary implications (staff contracts)

lprotect practice members as well as patients.

What areas do practices policies cover?

 · Employment issues ­ including staff contracts, checking credentials of new doctors and staff, appraisals, holiday rotas, the payroll, anti-discrimination policies, staff safety including dealing with violent patients, grievance and disciplinary procedures, use of occupational health department

 · Premises ­ health and safety, maintenance, renewals, emergency breakdown of supply, including

who is responsible and action to be taken

 · Patient confidentiality

 · Practice administration ­ requests for routine and emergency appointments or visits, repeat prescriptions, test results, patient complaints4 and adverse events5

 · Teaching and training

 · IT ­ coding, security

 · Clinical policies ­ immunisation, chaperoning, targets, practice formulary, NSFs, NICE6, cancer referra · 7 and other local/national policies.

How are policies drawn up?

The need for a policy may be dictated by external change or be identified from inside the practice as a result of observation, audit, significant event analysis or serendipity. This should be discussed at the outset with all those who will implement or are likely to be affected by the policy (doctors, nurses, receptionists, patients); they may have unexpected insights or skills, and must 'buy in' if the policy is to work.

It may be possible to define a policy at a single session, but further research or discussion is often needed. It may be a more efficient use of the group's time if one or two members are delegated to produce an initial draft; this can then be tested, modified and signed off by the group as a whole.

What should a policy include?

 · What, why, who, when, where and how

 · A circulation list

 · The name of the person responsible for the policy, the date it was agreed/updated, and a review date (normally annually as part of a review programme)

 · Safety-netting (for example, how the appointment system should be operated in the event of a planned computer shutdown or power-cut)

 · An integral audit where appropriate (for example, the complaints procedure4)

 · Supporting documentation (for example an NSF, Good Medical Practice8, clinical governance)

How can the GP registrar possibly be expected to know all the practice policies from day one?

You can't, and many practices list their important or commonly used policies in a welcome handbook. It is partly your trainer's responsibility to bring them to your attention, but it is also your responsibility to think about the consequences of any decisions you take.

You already have experience of working in a team, and will often be able to recognise situations where a common policy would be appropriate, so check your actions with another member of the practice if you suspect there is something you should know. Registrars are often helpful to practices because as newcomers

they spot weak links.

Key points

 · Practices need policies covering both clinical and administrative issues; these protect practice members as well as patients

 · Policies should be acceptable, evidence based where possible, and clearly disseminated to all who will use them

 · Policies should be reviewed, audited and updated regularly

 · Failure to follow policies should be raised initially with the relevant person; serious or repeated failure may have disciplinary implications

References and resources

1. National service frameworks ­ for CHD etc www.doh.gov.uk/nsf/nsfhome.htm

2. Clinical Governance www.doh.gov.uk/pricare/clingov.htm

3. Data Protection Act 1998 www.data-protection-act.co.uk

4. NHS complaints www.doh.gov.uk/complaints

5. NPSA ­ National Patient Safety Agency: reporting, analysing and learning from adverse incidents and 'near misses' involving NHS patients www.npsa.nhs.uk

6. NICE ­ National Institute for Clinical Excellence: publishes guidelines on drugs, chronic disease management and other interventions www.nice.org.uk

7. NHS Cancer Plan (2000) www.doh.gov.uk/cancer/cancerplan.htm

8. GMC Good Medical Practice 2001 www.gmc-uk.org/standards/good.htm

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