Delegation and Referral
When patients are moving between care settings, it is vital that they have a clear understanding
of what is happening.
In both cases of delegation and referral, we agree that doctors should be in a position to
explain why all or part of their care is being transferred to another colleague and must also
ensure that patients understand who will undertake overall responsibility for their care and
treatment going forward. This must also include when patients who have been treated in
secondary carer are sent back to their GP for follow ups. We know that often patients are
confused about whether the Consultant or their GP is then responsible for their ongoing care.
Patients should also be made aware of any further discussions about them or their care that
will occur between their GP and Consultant
It must be the responsibility of doctors to ensure that all relevant and critical information is
passed on to the relevant healthcare professional to ensure their safe and effective care. This is
one of the key areas of confusion and delay, particularly when patients are being moved
between secondary care and domiciliary care, although problems are not confined to this area.
Where patients are not happy for their information to be shared, doctors must respect that
decision but explain why they believe the sharing of such information is necessary, and where
possible make alternative arrangements. It must be made clear to patients that their ongoing
health and wellbeing could be adversely affected if they do not undergo such treatment so they
can make an informed choice.
One aspect which is not touched upon is where a recommended referral has not been followed
through. We know from callers to our Helpline and from information from surgeons and GPs
that it is becoming increasingly difficult for patients to be referred onto surgery for some
conditions. This has included in recent years hip replacements, knee operations and cataract
surgery. Where patients have been told by their GP or have been made aware by other means
that they may be referred for surgery or other treatment but that referral has been blocked,
the reasons behind that decision should be explained to them. They should also be made aware
of the special funding request system which may allow them to access the treatment they
need.
Ending your professional relationship with a patient
In our response to the consultation on Good Medical Practice earlier this year, we noted the
inclusion of guidance on not ending the patient-doctor relationship due to a complaint and the
promise of fuller guidance later in the year. We welcome the opportunity to does so now.
We welcome the inclusion of a warning that persistent failure to fulfil this guidance could result
in disciplinary procedures including erasure.
Many patients have contacted the Patients Association’s Helpline saying that their GP has
deregistered them following a complaint. In 2001 a survey was undertaken of GPs in Northern
Ireland asking why they had removed patients from their lists1 at least 2 GPs admitted removing
patients from their lists for making a complaint. This is unacceptable. Across healthcare,
feedback from patients through complaints should not be treated as something to be
obfuscated. Rather, it should be seen as an opportunity to identify where something has gone
wrong, put procedures in place to rectify the problem, and learn from the mistake to ensure it
never happens again.
We are concerned about the discretion given to doctors with regards to legitimate reasons for
ending a professional relationship. Obviously, abuse of staff or theft from the premises are
understandable, although they may not make sufficient allowances for patients with mental
health issues. However, “persistently acted inconsiderately or unreasonably” leaves a wide
scope for doctors to claim irrevocable breakdown of the relationship. What about patients who
refuse to take part in immunisation or screening programmes? Guidance elsewhere states that
these are not acceptable reasons for GP registration. Yet a study in Sheffield2 found distinct
correlations of high numbers of patient removals around the time of immunisation and
screening (i.e young children (MMR) and young women (cervical screening)).
We note that the guidance also states that patients should not be deregistered on financial or
resource grounds. Yet in the same study in Sheffield, there was a spike in deregistrations
amongst elderly patients whose healthcare needs were higher. There have also be notable
instances in recent months where the press have revealed deregistrations due to resources.
This will become more worrying and pressing an issue for both patients and clinicians as GPs
undertake greater responsibility for the finances of the NHS.
In conclusion we would like to see a much narrower definition of what a breakdown in a
relationship looks like rather than allowing doctors so wide a discretion.
We do welcome the stronger guidance on ensuring doctors are ready to explain why they have
deregistered a patient. However, it could be stronger. We would prefer a “must” in telling “the
patient of your decision and your reasons for ending the professional relationship in writing, if
1
D O’Reilly, A Gillilan, K Steele, C Kelly; Reasons for Patient Removals: Results of a survey of 1005 GPs in Northern
Ireland
2
J Munro, J Skinner; The Epidemiology of Removal from GPs’ lists in Sheffield
practical.” This is certainly the position of the Health Service Ombudsman who last year was
highly critical of the failure of many doctors to adequately make such explanations.3
We also welcome provision for ensuring that arrangements are in place to ensure continuity of
care for patients once they have been deregistered. We do not believe that the suggested
guidance goes far enough. We have heard several cases where patients are passed or blocked
from several GP lists in a row. Even after PCTs step in to try to assign patients to lists, they have
struggled. We are particularly concerned about how this process will work when the new CCGs
undertake their full responsibilities. Finally we note that the cost to the NHS of attending
Accident and Emergency, the only viable alternative when not registered with a GP, is
approximately 4 times as the cost of GP consultation. In this time of financial squeeze, such
expenses cannot be afforded.4
Financial Arrangements and Conflicts of Interest
With GPs undertaking greater responsibility for commissioning services, and the increase in
private provision of services, we are concerned about potential conflicts of interest. It would be
unconscionable to allow doctors to commission service in such a way that they would
financially benefit from them. It is detrimental to trust between individual doctors and patients,
and indeed could be deleterious to the reputation and confidence in the medical profession.
Decisions about patient care must always be made on clinical bases and should never be
allowed to be influenced by personal or corporate financial consideration. Any guidance on this
matter must be crystal clear on this point. We welcome the strong guidance on this point and
would be interested to find out more about what enforcement or disciplinary procedures may
be brought against doctors who fail to declare or allow conflicts of interest to cloud or influence
their clinical judgment.
Maintaining Boundaries
It is important that doctors ensure that patients have given informed consent before
undertaking any type of examination. In particular if medical students will be present or
involved in the examination, this is made clear to patients beforehand.
We agree with the guidance on ensuring that a chaperone is made available for patients and
that, that option is discussed with them before hand. Special consideration should be made for
3
Parliamentary and Health Service Ombudsman; Listening and Learning: The Ombudsman’s review of complaint
handling by the NHS in England 2010-11; London; 2011
4
Personal Social Services Research Unit, 2009, Unit Costs of Health and Social Care 2009,
http://www.pssru.ac.uk/pdf/uc/uc2009/uc2009.pdf
patients from other faiths or BME groups who may be uncomfortable with certain doctors
undertaking particularly intimate examinations.
Patients are often in a very vulnerable position when they see their doctor and it is imperative
that no patient ever feels pressured into having a relationship or forced to do something they
feel uncomfortable with. It is the responsibility of the doctor to maintain those boundaries at all
times when they are treating their patients. This consideration should extend after the
professional relationship has ended and ensure that former patients are not taken advantage
of.
We welcome strong guidance on reporting inappropriate sexual conduct of other colleagues.
Personal Beliefs and Medical Practice
Reiterating our response to the full consultation on Good Medical Practice, we agree that
doctors should not be forced to undertake treatments that they feel morally or religiously
opposed to. However, it is vital that those patients who wish to access these treatments are
able to do so quickly and easily.
Doctors must make it clear that the patient has the legal right to the treatment but that they
personally do not feel able to provide that treatment. Doctors should ensure they do not come
across as judgmental.
We believe that doctors should go beyond saying that another doctor may be able to provide
treatment and actively make contact with that doctor in every case, not just in circumstances
where the patient is disabled or seriously ill.
Doctors should take great care never to insult or impugn upon the religious or personal beliefs
of their patients. We note the example of blood transfusions and Jehovah’s Witnesses. Patients
have every right to refuse treatment if it goes against their beliefs. Doctors should explain
exactly what refusing the treatment will mean but allow the final decision to be the patients.
On the flip side, it would inadvisable and inappropriate for doctors to preach at patients. These
are often very vulnerable people who deserve to be treated better. The doctor’s beliefs should
never be imposed upon the patient. If a patient invites a conversation about personal beliefs or
faith, it may then be appropriate to talk about them.
Doctors’ use of social media
Doctors are of course free to use social media like any other citizen. However, they should be
conscious of the risk of breaching appropriate boundaries between doctor and patient and
ensure that those boundaries are maintained at all times.
Doctors should also be conscious of the widespread access to much social media, eg Twitter,
which could mean that their social media engagement could endanger public confidence in the
profession.
Finally, confidential information should be kept private and safe and should never be shared in
any media, including social media.