More and more is expected from GPs, and it is time to properly define boundaries, argues Dr Zoe Rog
A few years ago, I saw a patient who had been discharged from hospital. He was planning to complain to the hospital and wanted to know who was to blame for everything that had happened to him during his admission. He had initially attended for coronary angiography and had unfortunately experienced significant bleeding. This had led to a myocardial infarction and an ITU stay, during which time he had developed pneumonia and sepsis. He was significantly more frail and less able than he had been prior to the admission. This must, he reasoned, be someone’s fault.
I sympathised with his plight and agreed that he had certainly been very unlucky. We had a lengthy discussion about recognised complications and the fact that adverse health outcomes, while unfortunate, are not always the result of medical negligence. He thanked me for the explanation and admitted that I had changed his perspective.
Unfortunately, fewer patients these days are open to these kinds of discussion. It feels that not only is public perception of the limits of our responsibility becoming increasingly distorted, but also that our governing bodies and secondary care colleagues are contributing to this.
Our QOF targets suggest that we are responsible for childhood immunisation rates, even for those children whose parents continue to adamantly refuse to allow them to be vaccinated after multiple discussions. There is no exception coding for this. As far as I can tell, the only way we could influence this further would be to legally adopt those children so that we could personally consent to their immunisations.
CQC currently appear to be focussing on medication monitoring. I am a passionate advocate for robust systems around this, but we know that some patients will not regularly attend for blood tests and appointments no matter how hard we work to encourage and remind them. If we stop their medications and their conditions worsen then we will be held responsible. Many surgeries are doing a huge amount of work to support patients to attend for monitoring, but it feels as if they get little or no credit for this if there are still a small percentage who choose not to attend.
I continue to be asked to put my signature on assurances that patients are fit to join gyms, climb mountains, attend Camp America and perform specific duties in their workplace. I receive requests to write letters confirming that patients’ symptoms are due to the mould in their houses. Declining to so do and explaining why takes time and leads to complaints that take up further time. Letters from secondary care ask me to ‘kindly’ control patients’ Hba1c, assist them to lose weight and ensure they stop smoking.
The myriad of casual ‘GP to follow-up’ letters leaves us and our staff in a frenzy of time-wasting with unanswered telephone calls, disconnected phone numbers and surprised patients who feel fine and do not need follow-up. The forms we complete for the DWP, the DVLA and insurance companies expect unrealistic levels of detail about patients’ personal lives. Society seems to fail to realise that we don’t go home with our patients, do their shopping or go to parties with them. Many of our registered patients we have never even physically set eyes upon.
The complaints system drains our time and energy too. Patients can complain about anything as often as they like, and we are under pressure to send detailed and apologetic replies each time. I have had to defend bitter and lengthy complaints in the past because I sent factual information to the DVLA and to a child safeguarding conference as I was professionally obliged to do. I have witnessed colleagues in tears and questioning their future in the profession as a result of clearly vexatious complaints. Patients are allowed to make any number of unpleasant and untrue assertions about a GP’s professional competence and behaviour and we are still advised to provide contrite and apologetic replies.
At a time when primary care is underfunded, understaffed and under pressure, there are actions here that could be taken to support us and reduce our workload rapidly and without huge financial cost. The skewed boundaries of the complaints system and the primary/secondary care interface need to be reset. The Government could support us with a campaign making it clear that we cannot take ownership for all of society’s increasing demands and failings. The GMC may have revised the Duties of a Doctor, it is time for clarity regarding what those duties do not include and where the limits of our professional responsibilities reasonably lie.
Dr Zoe Rog, GP in Runcorn, Cheshire
READERS' COMMENTS [6]
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Wow, Zoe, are you actually admitting that you have never done a patients’ shopping for them?
And why do you not have them over to your parties?
Surely these are both part of a GPs essential duties?
You should take them away with you on more holidays too, or at least arrange to meet up while you are over there, seeing as most of them have longer holidays than you, so woud be travelling ahead and coming back later.
I am surprised you have not found these instructions in the GMC’s publications on ‘Duties of a Doctor’ – have you even read it?
if you don;t have a lot of time, it is just after the section where it mentions checking on each patient on their arrival back home from a hospital admission, to give them back their front-door key (having fed the cat during admission, and walked the dog twice daily) and check the fridge is full and the heating is on, and to kindly check that the TTOs are correct.
Really good article thank you. I had a complaint from a patient who felt I did not make enough eye contact and called me ‘disabled’. She put in the quotation marks. Not sure what they signified. My first apology she rejected so a second was required. The best thing was I went on a communication course with the MDU re complaints and as one doctor pointed out it was like a cross between AA and speed awareness course as we shared our stories of vexatious and copious complaints. It was therapeutic. Taking it less personally and getting less stressed. Still really annoying it takes time out of our own free time to do responses etc. Would be really good to have a local complaints based service that vets complaints eg ICS/LMC level that sends out a stock reply of no clinical fault, sorry your experience didn’t match your expectations. Like DRSS vets referrals. But of actual benefit to us. Won’t happn. But would save us time and stress and might even help with the burnout. Needs to be funded by NHSE though not coming out of GP funding pot. Far too under funded already.
A year or two back in the immediate post-Covid period we were told to prioritise work toward the most clinically important. Actually I’m uncertain if that directive was rescinded but that’s anther story… anyway as complaints officer I took this at face value and remade our complaints policy. Every compliant was objectively assessed to see if it highlighted any clinical failing or had any potential to escalate. Any complaint that was judged clinically inconsequential or borderline vexatious got a stock reply stating that the complaint had been judged of no clinical relevence and would not be further responded to until work pressures subsided. We had a handful of these, and got no absolutely push-back from the complainants. I think the point was to carefully assess the item at hand, deal with that fairly and safely and shred the rest.
CQC currently appear to be focussing on medication monitoring.
They are wanting 100% compliance in all these areas – or flag a safety concerns – but they are not able to justify how any target can realistically be expected to be 100%.
They fail to publish any data to support such unrealistic target expectations from their inspectors, even when multiple attempts to contact or call in these patients has not led to the patient attending.
CQC should publish a QOF like search that they expect fulfilled – with realistic targets that are achievable, as long as the practice has tried to get the patient to comply, it is acceptable.
Similarly – until the government makes it mandatory for parents to vaccinate their children, then opt out from parents in targets should be allowed. It is not for practices to suffer for vaccine hesitancy, without support from the DOH policy, Any refusers should be reportable to a ICB vaccines team and excluded once done – then a MDT team can take over persuading them to comply.
None of your suggestions will happen. Why? It is HMG’s intention that we are responsible for everything and have no right to say no to anything. All enforced by CQC and GMC.
@Krishna M… so, up the ante then. Refuse entry to premises by the CQC The buildings are ours, it would be trespass. Call the police if they don’t leave. Refuse appraisal and revalidation. Noncompliance with anything we (in our professional opinion) is waste-of-time bullshit. Fellow medics working for these organisations need to rediscover their Hippocratic oath and stop the harm they themselves are collaborating with.