Dr Zaid Al-Najjar and Sue Taylor answer questions about patient dealing with dissatisfaction effectively
Q. What are the recent and forthcoming changes/issues that will affect complaints made to GPs?
The English complaints procedure is still a two-tier system with Local Resolution initially followed by escalation to the Parliamentary and Health Service Ombudsman. Although patients are encouraged to raise their concerns directly with the practice, the PCT’s previous role in primary care complaints will now be led by NHS England.
The Ombudsman has recently announced that they will be investigating more complaints and as such it would be wise to ensure you have a robust complaints procedure in place and get advice from your medical defence organisation where necessary. These investigations will increasingly include face-to-face and telephone interviews, which practices should be prepared for.
The Independent Complaints Advocacy Service is now commissioned through the local Healthwatch. It would be wise to check the local contact details for ICAS services in your area as a number of providers changed on 1 April 2013.
Q. What are the possible costs incurred by the partners and/or practice in regards to complaints?
The Ombudsman’s ‘Principles for Remedy’ include the possibility of financial remedy at local resolution if the patient has suffered injustice and hardship as a result of maladministration or poor service.1 The Ombudsman expects the patient to be returned to the position they were in before the poor service took place, if at all possible. The Ombudsman can also make a recommendation of financial remedy if they investigate a complaint and find failure. The size of the payments can vary from less than £100 to several thousand depending on the complaint and the effect it has had on the complainant. It would be usual in a non-claim situation for the practice to pay the amount and then make a request to their medical defence organisation to consider reimbursement. However, not all complaints result in financial remedy, as other remedies can be appropriate, such as an apology or an improvement in service.
Q. How can we prepare for medical records being accessible online to reduce the risk of complaints?
The primary purpose of medical records is to document all matters related to the health of a patient and to ensure continuity of care. However, whilst the GP should write with a medical audience in mind they should be prepared to share and explain the content with patients.
GPs should ensure that medical records are clear, accurate and legible and only use abbreviations where their meaning is unambiguous and professional. They must ensure that information which may cause serious harm to the mental or physical health of the patient or third parties is excluded from access, if possible.
Patients have the right, under the Data Protection Act, to ask for factual inaccuracies in the record to be rectified or deleted. GPs should only comply with a request if you are satisfied that it is valid, although it is rare to delete an entry in its entirety. Any disputed entries can be annotated with the patient’s view. GPs should also consider advising patients on the importance of keeping their own records secure and allowing third parties to access them. If a third party was to view information that the patient may not be aware of or they did not want them to see, this could impact on the GP who may have to deal with the fallout.
Q. Should we always apologise? If not, when should we apologise/what for?
The General Medical Council (GMC) and the Ombudsman expect doctors who have made a mistake to apologise. If the doctor has identified something in a complaint which they feel is valid, and that may have been approached differently with the benefit of hindsight, it is appropriate to apologise for the error and explain how they have made changes to prevent it from happening again. The two reasons the majority of patients complain are because they want an apology and they want to ensure that what they have experienced won’t happen to someone else. The practice manager should work with the doctor to deal with these two points in a conciliatory and insightful manner.
If the doctor does not think they would have done anything differently, then empathising with the complainant’s distress and expressing regret is always helpful, alongside an explanation of what they did and the reasons for this. The complainant should then be invited to raise any issues they remain unhappy with or do not understand. There is no reason under such circumstances that you cannot apologise for any misunderstanding or distress experienced.
Q. What’s the minimum we should do for a patient who complains?
A complaint should be acknowledged within three working days and a timeframe within which to provide a reply negotiated with the complainant. This will depend on the gravity of the complaint and the likely extent of the investigation. The issues should be clarified with the patient so they can be investigated and responded to appropriately.
The GP partner or practice manager will often lead on investigating the complaint, including liaising with the patient, speaking to the staff involved and reviewing relevant guidance, medical records and local policies. The complaint response should include the results of the investigation and the practice’s conclusions along with detailed responses to the concerns.
If the patient remains dissatisfied they should be invited into the practice or submit any further queries they have which may conclude the matter. They should also be made aware of their right to take the matter to the Ombudsman and be advised of the local complaints advocacy service which they may like to approach for support and advice with the complaints process.
Q. How can doctors ensure probity in their personal lives, e.g. when online dating, using chatrooms?
Unguarded comments about patients, employers, or other staff members are unprofessional and can breach patient confidentiality. It goes without saying but comments of a racist, sexist or bigoted nature, or posting inappropriate images or extreme views, are unprofessional and likely to get doctors into trouble.
Doctors are advised to review privacy settings so that private posts do not become widely available and patient confidentiality must always be maintained. If a patient were to contact the doctor they should sensitively explain that it would be inappropriate to communicate due to their ethical and professional obligations.2
One particular aspect that can lead to seemingly unprofessional posts is the feeling of anonymity afforded to people by the internet. Doctors should be advised that they are not only representing themselves and the practice they work in, but also the reputation of the profession.
The GMC’s guidance on social media states that doctors should identify themselves online; however this is only if they are posting in a professional capacity. If a doctor is using social media for personal use, such as for online dating or using chat rooms or social media, they can do so under a pseudonym; however they should still write responsibly. It is wise to write assuming your identity will be known.
Q. What are some of the reasons defence subs seem high at the moment? Is it likely they will come down in time?
GP subscription rates have increased for 2013 as a result of the rising number and value of claims against GPs. We have seen the number of claims that GP members have reported to us increase by 40% from 2011 to 2012. The combination of increased frequency and severity has seen the cost of claims soar which has an impact on subscription rates.
We hope that the Legal Aid, Sentencing and Punishment of Offenders (LASPO) Act will bring about a fall in the number of new claims being made, or at least stem the tide, as this is likely to control the influx of no-win-no-fee action.
Q. What are they key ways to avoid a complaint about clinical negligence?
Last year the GMC revealed that complaints around the conduct of doctors had risen by 23% compared to the previous year.4 The three most prevalent types of complaint to the GMC were concerns with investigations or treatment; problems with communication and a perceived lack of respect. GPs should be advised:
Communication – Be aware of verbal and non-verbal communication and adapt the consulting style to the patient. Patients experience difficulties in assessing the technical competency of a doctor and will frequently judge the quality of clinical competence by their interactions with a particular doctor.
Expectations – As the gap between patient expectations and what the NHS can deliver continues to widen, patients are likely to be left dissatisfied. Although patients’ expectations are sometimes unrealistic, eg, the doctor will have unlimited availability, will solve all the issues at once and all treatments will be 100% effective, these expectations can be addressed if they are identified early on.
Competence – if a clinician reaches the limits of their ability to diagnose and treat the symptoms, be honest, reassure the patient that they can find nothing to treat at present, but leave the door open for the patient to come back, or suggest someone who could offer a second opinion.
Openness – If something does go wrong, be open and honest with the patient. Effective communication after an adverse outcome lies at the core of rebuilding trust and supporting healing for the patient, their loved ones and the healthcare team involved.
Q. What are the most common ‘career-ending mistakes’ GPs make?
Medicine is complex and no matter how technically gifted or professional a GP is, there is no immunity from human error. However, if a doctor can show insight and understanding as to why the error happened and how to prevent this from happening again it is likely that they will be able to continue practising. If a doctor shows no insight, this can pose a serious risk to the future of patient safety and can lead to being struck off.
Doctors may be reluctant to seek help for their health issues such as self-prescribing, substance or alcohol abuse or gambling addiction. If a persistent lack of insight about limitations to their competence, for any reason, puts patient safety at risk, their career may be at risk.
Dr Zaid Al-Najjar is a medicolegal adviser and Sue Taylor is a general practice complaints adviser. They both work for the Medical Protection Society (MPS).
Parliamentary and Health Service Ombudsman. Principles for Remedy http://www.ombudsman.org.uk/improving-public-service/ombudsmansprinciples/principles-for-remedy
GMC. Social media guidance. 2013 http://www.gmc-uk.org/Draft_explanatory_guidance___Doctors_use_of_social_media.pdf_48499903.pdf 3
GMC. The State of Medical Education and Practice in the UK. 2012