Professional support and expert advice for GPs and practice staff
UNITED KINGDOM | VOLUME 2 – ISSUE 1 | FEBRUARY 2014
When patients stalk
Unwelcome patient attention
PAGE 6
THIS ISSUE…
www.mps.org.uk
THE DRAMA TRIANGLE
CORE SKILLS – PRESCRIBING
How to maintain professional
boundaries
How to do it safely and effectively
RISK ALERT – CLINICAL
PROTOCOLS
YOUR VIEWS – CQC
INSPECTIONS
What protocols should be in place
to protect your practice
What do GPs really think?
2 | FEATURE
PAGE/SECTION HEADING
CONTENTS | 3
MEDICAL PROTECTION SOCIETY
PROFESSIONAL SUPPORT AND EXPERT ADVICE
How to contact us
www.mps.org.uk
THE MEDICAL PROTECTION SOCIETY
Get the most from
your membership
What’s inside…
MEDICOLEGAL
CAREERS
PRACTICAL PROBLEMS
06 Unwelcome patient
attention
14 Core skills series
– Prescribing
20 N
ew repeat
prescribing system
Sessional GP and MPS medicolegal
consultant Dr Rachel Birch shares a scenario
about a patient who stalked her GP
In this series we explore the key risk areas
in general practice. Charlotte Hudson
talks about the risks and what you can do
to avoid them
Irena Nestorowytsch-Irwin, business
manager at Dr Shorten and Partners,
Lisburn Health Centre, launched a new
system for ordering and collecting repeat
prescriptions by chemists
Victoria House, 2 Victoria Place, Leeds LS11 5AE
www.medicalprotection.org
www.dentalprotection.org
Please direct all comments, questions or suggestions
about MPS service, policy and operations to:
Chief Executive
Medical Protection Society
33 Cavendish Square
London W1G 0PS
United Kingdom
PUBLICATIONS
GP COMPASS HANDBOOK
[email protected]
E-LEARNING
PODCASTS
In the interests of confidentiality please do not include
information in any email that would allow a patient to
be identified.
UK medicolegal advice
Tel 0845 605 4000
Fax 0113 241 0500
Email [email protected]
UK membership enquiries
VIDEO
NEWS
Tel 0845 718 7187
Fax 0113 241 0500
Email [email protected]
UK GP Practice Xtra Package enquiries
Tel 0845 456 7767
Email [email protected]
www.mps.org.uk/gppractice
FACTSHEETS
TWITTER
RISK MANAGEMENT WORKSHOPS
www.mps.org.uk
The Medical Protection Society is the leading provider of comprehensive
professional indemnity and expert advice to doctors, dentists and health
professionals around the world.
MPS is not an insurance company. All the benefits of membership of MPS
are discretionary as set out in the Memorandum and Articles of Association.
CASE REPORTS
MPS has a wealth of resources that provide
medicolegal and risk management advice – but
did you know they are literally at your fingertips?
Visit the MPS website to access the full range of
material that is available to you – and start getting
the most from your membership.
The Medical Protection Society Limited. A company limited by
guarantee. Registered in England No. 36142 at 33 Cavendish Square,
London, W1G 0PS
Opinions expressed herein are those of the authors. Pictures should not be relied upon as
accurate representations of clinical situations. © The Medical Protection Society Limited
2014. All rights are reserved.
GLOBE (logo) (series of 6)® is a registered UK trade mark in the name of The Medical
Protection Society Limited.
17 Test your knowledge
GP and patient safety lead Dr Andrew
Tresidder explores how to maintain
professional detachment in a consultation,
drawing on the psychological concepts
around the drama triangle
Try these sample AKT questions on
prescribing provided by Dr Mahibur
Rahman from Emedica
10 Risk alert – Clinical protocols
Diane Baylis, MPS Clinical Risk Manager,
discusses how protocols enable practice
teams to practise the right way
18 In the hot seat:
Dr Darach Ó Ciardha
For a busy GP, any tool that can save time
and labour is valuable. Charlotte Hudson
chats with Dr Darach Ó Ciardha about the
launch of GPBuddy.co.uk
Dr Clare Etherington, Clinical Lead for MAP at
the RCGP, discusses the benefits of the new
route to membership for established GPs
23 Your views – CQC inspections
Our columnists share their views on CQC
inspectors
Every issue…
04 Noticeboard
05 Events
19 Hot topic – Child protection
Snippets of interesting medicolegal news
and updates on new guidance
A look at the top practice events for 2014
In this issue Professor Sir Peter Rubin,
chair of the GMC, looks at the thorny issue
of child protection
Visit our website for publications,
news, events and other information:
www.medicalprotection.org
Follow our timely tweets at:
www.twitter.com/MPSdoctors
Get the most from
your membership…
EDITOR-IN-CHIEF Dr Richard Stacey EDITOR Sara Dawson DEPUTY EDITOR Charlotte Hudson CONTRIBUTORS
Dr Mahibur Rahman, Irena Nestorowytsch-Irwin, Dr Laura Davison, Diane Baylis, MPS Education and Risk Management,
Dr Euan Lawson, Dr Andrew Tresidder, Dr Darach Ó Ciardha, Dr Rachel Birch, GMC, Professor Sir Peter Rubin DESIGN
Jayne Perfect PRODUCTION MANAGER Philip Walker MARKETING Peter Macdonald, Beverley Hampshaw
EDITORIAL BOARD Dr Stephanie Bown, Gareth Gillespie, Shelley McNicol, Julie Price
MPS is not an insurance company. All the benefits of membership of MPS
are discretionary as set out in the Memorandum and Articles of Association.
22 RCGP launches new Membership
by Assessment of Performance
(MAP)
Practice matters (Print) ISSN 2052-1022
Practice matters (Online) ISSN 2052-1030
Cover: Composite image includes: © -goldy-/iStock/Thinkstock, © Ingram Publishing/
Thinkstock, © minemero/iStock/Thinkstock
Visit www.mps.org.uk
08 The Drama Triangle
We welcome contributions to Practice
Matters, so if you want to get involved,
please contact us on 0113 241 0377 or
email: [email protected].
MPS1493:12/13
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
4 | NOTICEBOARD
PAGE/SECTION HEADING
Dr Richard Stacey
Editor-in-chief and MPS medicolegal adviser
Whilst it is right to offer patients advice
and support, there may be circumstances
where a patient starts to rely excessively on
contact with you. It may be very flattering if a
patient tells you that you are “the only doctor
that understands”, but remember there may
be a hidden danger within these words.
In this issue of Practice Matters we share a
case where a locum GP received unwanted
attention from a patient. Remember that
although you are a doctor, you and your
family are entitled to the same privacy
and protection as other people. It can be
extremely distressing to be the subject of
unwanted attention and stalking behaviour
from current or former patients.
The key to dealing with this scenario is to
recognise early the signs that a patient is
starting to become over-reliant on you. If
this is the case consider asking them to
attend another GP within the practice for a
second opinion. The GMC says if a patient
pursues an improper emotional relationship
with you, you should treat them politely
and considerately and try to re-establish a
professional boundary. If you have concerns
in this area, contact MPS for advice.
A round-up of the most interesting
news, guidance and innovations
MPS surveys of GPs
and public reveal lack of
information around care.data
S
ixty-seven per cent of adults in England
say they have not received the leaflet
from NHS England explaining the new care.
data system, and 45% do not understand
care.data from what they have heard or read,
according to a recent survey.
A YouGov survey commissioned by MPS
asked more than 1,400 adults in England
about care.data, which is a national database
that will hold and analyse information from
patients’ medical records with the aim of
improving the quality of care.
Furthermore, a separate MPS survey of
more than 600 GPs has revealed 77% do not
think NHS England has given them enough
information to properly inform patients about
care.data, while 80% of GPs do not believe
they have a good understanding of how patient
data will be used in the care.data system.
Dr Pallavi Bradshaw, medicolegal adviser
at MPS, said: “While we recognise that
sharing information about patients could
Remaining professionally detached is
part of being a good GP, but it is not easy.
In ‘The Drama Triangle’ on pages 8-9,
GP and patient safety lead Dr Andrew
Tresidder explores how to maintain
professional detachment in a consultation
drawing on psychological concepts
such as the Drama Triangle, the Four
Agreements and the Seat of Power. Dr
Tresidder says that as practitioners we
must avoid allowing patients to transfer
responsibility for their health to us, or risk
being persecuted when things go wrong.
transform the way the NHS cares for
and treats people, it is worrying that GPs
feel that there is a lack of information for
patients to make an informed decision about
their personal data. This is a huge step in
modernising health services, which most
people will only find out about in a maildrop to households and that may get lost or
discarded along with take-away menus and
supermarket offers.
“There is no doubt that technology offers
enormous opportunities in managing
healthcare, but we do not want this to be
at the cost of trust between the doctor and
patient. Although the results tell us that half of
patients are not concerned about their medical
records leaving the GP practice, we worry
that this is because, historically, patients have
had confidence in their GP to look after their
personal data. Some patients may see the
scheme as an unwelcome intrusion into their
personal lives which could irreversibly damage
the relationship with their family doctor.”
A separate MPS survey of more
than 600 GPs has revealed 77% do
not think NHS England has given
them enough information to properly
inform patients about care.data
As Practice Matters went to press NHS
England announced that it planned to
delay the collection of patient data into the
care.data system.
Dr Bradshaw continued: “MPS is pleased
to see that the launch of care.data is being
postponed by six months, which will give
NHS England the opportunity to address
the concerns that have been raised. This roll
back will enable NHS England to fully inform
the public and GPs about this fundamental
change to the use of personal data, which is
hoped will transform our health services.”
He writes that in life everything is always
changing – if we do our best, whatever the
circumstances, we express ourselves with
integrity and avoid self-criticism and regret.
We hope you enjoy this edition of Practice
Matters and would be interested to hear
your comments, as well as any topics you
would like us to feature in future editions.
Please email [email protected].
To find out more information on the care.data system, visit the NHS England
website: www.england.nhs.uk/ourwork/tsd/care-data
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
NEWS IN BRIEF
Regulation update
The Care Quality Commission has
published A fresh start for the regulation
and inspection of GP practices and
GP out-of-hours services. It sets out
the CQC’s early thinking on how they
will monitor, inspect and regulate GP
practices and GP out-of-hours services.
The new approach will include the five
key questions to be asked of services
– are they safe, effective, caring,
responsive to people’s needs and wellled. www.cqc.org.uk/public/news/
inspecting-and-regulating-gps-andout-hours-services
Guidance
The Department for Work and Pensions
has issued Getting the most out of the
fit note: Guidance for GPs. It provides
information on completing each
section of the fit note (including the
reassessment box, comments section
and return to work tick boxes), and
uses case studies to illustrate different
situations. www.gov.uk/government/
publications/fit-note-guidance-for-gps
Legal update
The Defamation Act 2013 came into
force on 1 January 2014 and the Ministry
of Justice has published guidance on
Section 5 of the Act – Complaints about
defamatory material posted on websites:
Guidance on Section 5 of the Defamation
Act 2013 and Regulations. Section 5
of the Act creates a new defence to an
action for defamation brought against
the operator of a website hosting usergenerated content, where the action
is brought in respect of a statement
posted on the website. www.gov.uk/
government/publications/defamationact-2013-guidance-and-faqs-onsection-5-regulations
Useful links
The House of Commons Library has
produced an information note on Child
protection: Duties to report concerns.
It provides information on the duties
on those who come into contact with
children as part of their professional
lives to report suspected abuse or
neglect of children. It also highlights
recent calls for a mandatory duty to
report suspected abuse or neglect.
Experts call on GPs
to rethink age-related
hearing loss
A panel of audiology and primary care experts are calling on GPs
to rethink how they manage age-related hearing loss (ARHL).
The experts argue traditional clinical settings may compound
stigma, creating barriers to engagement with services. In a new
report authors contend that use of high quality, comprehensive
NHS hearing care within local, ‘non-clinical’ settings for
appropriate patients helps reduce stigma and improve outcomes.
Hear and Now – Why GPs need to rethink age-related
hearing loss highlights the benefits of early intervention, calling
for attendance at a local community based audiology service,
and for ARHL to be regarded in the same way as a trip to the
opticians or a check-up at the dentist.
“A local audiology setting may increase the person’s feeling
of control and autonomy, which are central to self-efficacy and
empowerment models of health promotion. Health promotion
should be democratic, needs driven, and about taking control
and enhancing decision-making,” said Dr Stuart McClean,
Medical Anthropologist, University of the West of England.
The report includes a hearing loss checklist for GPs and
routine health checks.
For more information visit: www.hearinglink.org.
The report is available to download here.
Practice notes
A practice manager
contacted Practice Matters
with this tale:
© MONKEY BUSINESS IMAGES LTD/THINKSTOCK
Welcome
PAGE/SECTION
NOTICEBOARD
HEADING | 5
Recently a complaint
from a patient regarding
confidentiality went to the
ombudsman and was upheld.
The patient was an ex-police
officer. He complained
because a receptionist
had asked for his address
at the reception desk. His
complaint was that the
receptionist should not be
asking for addresses at the
reception desk as this could
be overheard by another
patient. He believed this
had led to his house being
burgled. The ombudsman
agreed with him.
Events…
SSPC Annual
Conference
Management in
Practice
MPS Practice
Management Seminars
This conference brings
together a broad range of
healthcare practitioners,
researchers and academics
from all over the world
When: 25 April
Where: Glasgow
More: w
ww.sspc.ac.uk/
conferences
This event covers all the
major issues that impact
on the management of
primary care
When: 5 June
Where: Manchester
More: www.management
inpractice.com/
events
Pulse Live
MPS GP Conference
This year’s agenda
provides a stimulating mix
of sessions tailored to the
learning needs of GPs and
practice managers
When: 29-30 April &
12-13 June
Where: L
ondon &
Manchester
More: www.pulse-live.co.uk
MPS’s annual event for
GPs and practice managers
promises to be bigger and
better than last year
When: 12 & 19 June
Where: L
ondon &
Manchester
More: www.mps.org.uk/
gp-conference
These interactive seminars
give practical tools to
improve your practice
When: All year
Where: Across the UK
More: www.mps.org.uk/
PMSeminars
MPS HR and
Employment Law
Seminars
Aimed at practice
managers, these seminars
give you the tools to tackle
HR and employment law
When: All year
Where: Across the UK
More: w
ww.mps.org.uk/
HRSeminars
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
6 | MEDICOLEGAL
MEDICOLEGAL | 7
COVER FEATURE
is not seen until the next working
day. Advise patients not to contact
you by email for the above reasons.
Ensure that you inform the practice
manager about the emails you
have received. Emails and texts
from patients should be filed in their
medical records.
■■ Remember to maintain professional
boundaries with patients. The GMC
advises that “if a patient pursues
an improper emotional relationship
with you, you should treat them
politely and considerately and
try to re-establish a professional
boundary”.3 In Dr L’s case the
comment about him being married
should have alerted him to the fact
that the professional boundary was
becoming compromised.
■■ Consider whether the patient may
have a mental health disorder
and discuss this with colleagues
and offer a psychiatric opinion if
indicated.
■■ If the patient’s behaviour doesn’t
stop, you may feel that there is a
breakdown of trust between you
and the patient. You should discuss
the matter with your GP colleagues.
Ensure that you follow GMC
guidance.4 Discuss your decision
Unwelcome
patient attention
Sessional GP and MPS medicolegal consultant Dr Rachel Birch
shares a case scenario about a patient who stalked her GP
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
was in town she would seem to “bump into him”.
He realised how serious things had become
when his wife received a letter from Miss X stating
that she was in love with Dr L and would not stop
following him until her feelings were reciprocated.
How to avoid this scenario
Whilst it is right to offer patients advice and
support, there may be circumstances where a
patient starts to rely excessively on contact with
you. It may be very flattering if a patient tells you
that you are “the only doctor that understands”,
but remember there may be a hidden danger
within these words.
■■ Recognise the signs early that a patient may
be starting to become over-reliant on you. In Dr
L’s case Miss X moved practices to continue a
professional relationship with him.
■■ If you feel that a patient is consulting too
regularly, consider asking him/her to attend
another GP within the practice for a second
opinion. There are times when an objective
viewpoint can help, especially if the patient has
unresolved symptoms.
■■ There are occasions where a patient may
obtain your mobile number – for example, if
you have called them to ask for directions for a
home visit. If you start to receive calls or texts
on your mobile phone, politely and firmly ask
the patient not to contact you in this way and
ask them to contact the practice if they wish to
make an appointment with you.1
■■ There are risks associated with patients
emailing doctors, especially if doctors are
part-time and are not able to access their
emails regularly.2 There is also the danger that
a patient sends an email out of hours and it
© IAKOV FILIMONOV/ISTOCK/THINKSTOCK
Over the following months
Miss X managed to obtain
Dr L’s mobile number and
his work email address
r L worked as a locum GP in Manchester,
doing maternity and other long-term locum
jobs within the city practices. Five years ago he
saw a female patient, Miss X, with mental health
symptoms. He spent time trying to help her to
resolve some of her issues. She was referred to
counselling and to psychiatry and was found to
have a borderline personality disorder.
Dr L’s six-month locum post ended and he
moved to a neighbouring practice. Two weeks
into his job he was asked to see a new patient…
Miss X. She told him she felt he understood her
and wanted to remain his patient. He saw her as
a patient for the next four months, but then he
moved to another practice in the area. Again Miss
X registered at the new practice.
Over the following months Miss X managed
to obtain Dr L’s mobile number and his work
email address. She started to send daily
texts and then emails. The nature of her
correspondence gradually changed and in one
text she commented on the fact that she was
disappointed that he was married.
Although Dr L asked her several times to stop
texting and emailing him, she continued to do so.
The content of her messages implied that she was
“collecting” information about him. She started to
comment on his wife’s appearance, and admitted
that she was visiting his wife in the local jewellery
shop where she worked. She told Dr L to get his
front lawn landscaped and made reference to the
colour of his bedroom curtains.
Dr L asked Miss X in for a review appointment
and asked her to stop contacting him and to
see one of the other doctors in the practice. She
became upset but agreed to do so. He no longer
saw her as a patient, but found that whenever he
COMPOSITE IMAGE: © -GOLDY-/ISTOCK/THINKSTOCK, © INGRAM PUBLISHING/THINKSTOCK, © MINEMERO/ISTOCK/THINKSTOCK
D
and your reasons with the patient
and ensure that he/she has access
to appropriate follow up, perhaps in
the first instance with one of the GP
principals.
■■ Document all the steps you have
taken carefully and keep a record of
these. Keep a log of all the emails,
texts and letters you have received
in case of a future complaint against
you by the patient.
■■ Consider discussing your concerns
with your medical defence
organisation and follow their advice.
If the above measures don’t
work…
Remember that although you are a
doctor, you and your family are entitled
to the same privacy and protection
as other people. It can be extremely
distressing to be subject to unwanted
attention and stalking behaviour from
current or former patients.
■■ Continue to document any unexpected
contact you have with the patient. This
may be required as evidence if you
have to take further action.
■■ Remember you have a duty of
confidentiality to patients, so do not
discuss clinical details with your own
family or friends.
Keep a log of all the
emails, texts and letters
you have received in case
of a future complaint
against you
■■ In
such circumstances, you should
only disclose the minimum, relevant
information and you should take
care to avoid disclosing clinical
information.
As this case illustrates, although
such a scenario is more likely to be
encountered by GP principals, locums
are not immune to unwanted attention.
If you have any concerns in this
area, contact your medical defence
organisation for advice.
REFERENCES
1. MPS, Communicating with patients by text message (2013) –
www.medicalprotection.org/uk/england-factsheets/communicating-withpatients-by-text-message
2. MPS, Communicating with patients by fax and email (2012) –
www.medicalprotection.org/uk/england-factsheets/communicating-withpatients-by-fax-and-email
3. GMC, Maintaining boundaries: maintaining a professional boundary between you and
your patient (2013) – www.gmc-uk.org/guidance/ethical_guidance/21170.asp
4. GMC, Ending your professional relationship with a patient (2013) –
www.gmc-uk.org/guidance/ethical_guidance/21160.asp
Dr L asked Miss X in for a
review appointment and
asked her to stop contacting
him and to see one of
the other doctors in the
practice. She became upset
but agreed to do so. He no
longer saw her as a patient,
but found that whenever
he was in town she would
seem to “bump into him”
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
8 | MEDICOLEGAL
MEDICOLEGAL | 9
E
Dr Andrew Tresidder is a GP Patient Safety
Lead for Somerset CCG, GP Appraiser,
member of the Somerset Clinician Support
Service, and member of the European
Association of Physician Health. He is
a former Somerset LMC rep and Bristol
Medical School Academy GP Lead.
RES
C
The sign on an Australian
GP’s door reads: “Your
health is my concern,
but your responsibility”.
As practitioners we must
avoid allowing patients
to transfer responsibility
for their health to us
ffective communication makes for good
consultations, but some simple factors can
easily turn a good consultation into a poor one.
Psychological factors such as the Seat of Power,
the Drama Triangle and the Four Agreements all
apply to good communication and can make or
break its success.
“Every profession is a conspiracy against
the laity,” wrote George Bernard Shaw in The
Doctor’s Dilemma. Two people approach a
consultation, both independent adults. The expert
knowledge lies with the professional – the layman,
through ignorance or fear/anxiety, may give away
his power and autonomy to the professional.
The wise professional – remembering
Transactional Analysis and the three roles of Parent,
Adult, Child – shares power as much as possible
(Adult to Adult), uses it wisely for the patient,
then hands it back; finishing the consultation with
both people as independent adults once more.
Otherwise, patient and physician enter the Drama
Triangle of relationships.
The Drama Triangle has three roles – one Child,
and two Parent. The Child gives away their power
to a Parent, then plays Victim, with the script
“If you help me/save me/protect me, I will give
you my power (and my approval)”. The Parent
(very often the physician) takes the power and
becomes Rescuer (doctors go into medicine
to help people get better). The underlying
assumption may run “If you give me your power, I
will protect and help you (as long as you also give
me your approval)”. Sometimes the doctor’s inner
Child craves the approval of the patient’s Parent.
Patients may judge doctors on the basis of how
they feel – in which case there are only two types
of doctor – good and bad – or even the ‘best
in the world’ and ‘rubbish’. And the difference
between the two? Half a second – because
that’s how long it takes Victim to change
their mind about Rescuer, take back
their power, and change role into
Persecutor: “You nasty person, you
took my power and abused me,
now I’m going to abuse you.”
The sign on an Australian GP’s
door reads: “Your health is my
concern, but your responsibility”. As
practitioners we must avoid allowing
patients to transfer responsibility
for their health to us, otherwise we
happily accept the Rescuer role,
and should not be surprised to be
persecuted when things don’t go well.
It is very easy to be enticed into, and
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
then chased around, this triangle of dependency.
The sting in the tail (Edwards’ insight) is when the
patient sees illness, death, cancer or any medical
diagnosis as Persecutor, takes the role of Victim,
and sets up the physician as Rescuer – in a nowin situation.
It takes considerable skill for the physician to help
lift the patient out of the Child role of victim, yet can
be part of the most rewarding aspects of medicine.
One key pitfall is to avoid being enticed into
collusion with the patient. It’s very easy to agree
to support the patient (in their angry or distressed
state) – and find oneself moved from Rescuer into
Persecutor, possibly against a fellow professional.
Unconscious collusion in the Drama Triangle
is emotionally draining and may lead towards
physician burnout – it certainly leads to mutual
patient and physician dissatisfaction. An
understanding of these dynamics can illuminate
consultations and help avoid both complaints
and emotional exhaustion.
Don’t waste the power of your word in
idle gossip or putting yourself down. Use
your word, as a vehicle for the power of
your will, for good, with integrity – if you
lie, you’re only lying to yourself.
personally – for nothing is done
personally, even though it feels it. If I do
take it personally, then I choose to suffer!
Make no assumptions
Ask the little question “Why?” often,
and find clear answers for yourself.
Express your wishes clearly to avoid
misunderstanding. Communicate
clearly with others to avoid needless
mistakes, upsets and emotions.
Take nothing personally
Even though we are all part of an
interconnected universe, we each
have our own experiences and
interpretations. My stuff is my stuff, yours
is yours. Nothing you do is because of
me – it’s your stuff. How I interpret that is
my stuff – but better to take nothing
ER
SECUTO
Always do your best
R
In life, everything is always changing
– if we do our best, whatever the
circumstances, we express our selves
with integrity and avoid self-criticism
and regret. Beware emotional
attachment to the outcomes of
your efforts. Everything we
do is guided by positive
intention – try and find out
what the other person’s
positive intention is, and
life becomes a whole
lot easier.
What are the answers?
Firstly, be authentic – be yourself, and understand
the traps of the Drama Triangle. To thine own self be
true (Shakespeare). Second, read Games People
Play by Eric Berne. Third, use The Four Agreements;
native South Americans, the Toltecs, developed a
system of wisdom about how to live life – it is said
that four key points were these “agreements”.
VICTIM
Be impeccable with your word
Your word is an affirmation of your intent, a casting
out of your will into the world, reinforced by power.
So, say only what you mean, and speak with integrity.
R
E
U
USEFUL LINKS
arpman, S, Fairy tales and script drama analysis, Transactional Analysis
K
Bulletin, 7(26), 39-43 (1968)
■■ Edwards, G, Conscious Medicine, Piatkus pp130-133 (2010)
■■ Ruiz, DM, The Four Agreements, Amber-Allen Publishing (1997)
■■
© MONTY RAKUSEN
© KATARZYNABIALASIEWICZ/ISTOCK/THINKSTOCK
GP and Patient Safety Lead Dr Andrew Tresidder explores how to
maintain professional detachment in a consultation, drawing on
the psychological concepts around the Drama Triangle
P
The Drama Triangle
Case study
GP Dr A consulted 57-year-old Mr J. He
complained of considerable pain in his left knee.
The pain had stopped him playing golf, although he
continued to work. His BMI was 35. Dr A strongly
advised him to lose weight, and gave analgesia. An
x-ray showed moderate osteoarthritis.
After six months Mr J insisted on referral to an
orthopaedic surgeon Mr B, as his medication had
not helped the pain. His weight was unchanged.
Dr A reluctantly referred him. Several months later,
after the usual pre-op counselling that included
possible complications, Mr B performed an
uncomplicated left total knee replacement.
A year later he returned to Dr A, angrily
complaining that the knee was worse, and that he
was in constant pain. He said he wished he’d never
been referred, because then he wouldn’t have had
the operation. He threatened to sue Dr A and Mr B.
Learning points
The patient, in Victim mode, took no personal
responsibility for his weight and health condition,
but looked for someone else to sort it out (first a
GP and then a consultant as Rescuer). When he
had no benefit, even though he knew this was
a possible outcome, he felt Victim to the pain,
decided to take back his power and wield it,
this time as Persecutor.
Mr J then sought to make the GP collude
with him in his attempt to shift responsibility
for his condition squarely onto someone
else. Dr A could either deal with the issue or
avoid it. If Dr A seeks to avoid the thorny issue
of helping Mr J gain insight and maturity about
the position, Dr A may be pulled into the role of
Persecutor against Mr B.
If he seeks to deal with it, Dr A may have a
challenge to help Mr J come to terms with the
consequences of his own decision because Mr
J has already shown his disinclination to take
responsibility. However, this is the only long-term
win-win solution.
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
10 | MEDICOLEGAL
MEDICOLEGAL | 11
Clinical protocols
The employer, which in general practice is
typically the GP partners, is responsible
for ensuring that staff are properly trained
Diane Baylis, MPS Clinical Risk Manager, discusses how
protocols enable practice teams to practise the right way
linical protocols represent the
framework for the management of a
specific disorder or clinical situation and
define areas of responsibility. They reduce
variation, maintain the quality of patient
care and are documentary evidence of
the standard of care to be provided.
Producing clinical protocols is a useful
educational exercise that allows the team
to review their current practice in light of
national guidelines. In MPS’s experience
many practice nurses, although adhering
to national guidance, do not have locallyproduced clinical protocols.
MPS performs Clinical Risk
Assessments on thousands of practices
every year.1 During CRSA visits in 2013
MPS found that 78.4% of the practices
visited had issues relating to protocols.
In MPS’s experience many practice
nurses, although adhering to
national guidance, do not have
locally-produced clinical protocols
The issues were:
than 46.4% had no/poor/
unsigned clinical protocols
■■ More than 41.8% had issues relating
to archiving.
You should ensure that your local
practice protocols address the following:
■■ K nowledge and skills framework to
assess clinical competency
■■ Consent
■■ Risk assessment of procedures and
environment
■■ Documentation and record keeping
■■ Evidence/research based in line with
national guidance
■■ Reflect local services
■■ Identify who carries out key parts of
the care
■■ The use of Patient Group Directions,
and Patient Specific Directions where
appropriate.
■■ More
Disease management protocols usually
also:
■■ Define the circumstances where
patients are referred on from nurserun clinics to either a GP or directly to
secondary care
■■ Describe the practice’s criteria for
stepped increases in therapy.
There is a danger that protocols can be
developed by one individual in isolation,
resulting in a lack of ownership by other
members of the practice team. This can
result in protocols that are rarely adhered
to, and are only occasionally updated.
This will detract from their usefulness
and result in members of the practice
team working in different ways, with
variable standards. Protocols should:
■■ Be discussed and agreed by the
relevant members of the team
■■ Be developed with contributions from
representatives from different parts of
the practice
■■ Be revised regularly and amendments
made if necessary
■■ Be easily accessible.
Protocols should be clearly marked
with dates of creation, ratification and
future review, the version number of
the policy and they should be reviewed
annually. Outdated protocols should
be retained for at least eight years,
in case of litigation. Failure to retain
copies of historic policy documents
can make it difficult for organisations to
successfully defend claims. Claims can
date back many years and it is essential
that the practice is judged against the
expectations and knowledge at the time.
Patient Group Directions (PGDs)
PGDs are written agreements for the
supply and administration of medicines
by registered nurses (who are not
prescribers) to a group of patients who
may not be individually known before
they present for treatment.
Since August 2000, PGDs are a
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
statutory instrument and are legally
binding and they should be individually
negotiated between the nurse and
employer. PGDs must be signed by a
doctor and pharmacist and must meet
specific criteria.2
Since April 2013, the responsibility for
the authorisation of PGDs now lies with
the CCGs. NICE have recently published
guidance regarding PGDs.3
Examples of common patient groups
in general practice are:
■■ Infants and children requiring
immunisation
■■ Those requiring immunisation for
foreign travel
■■ Those requiring medication for
common acute or chronic illness.
properly trained and undertake only
those responsibilities specified in their
job descriptions. If non-regulated staff
are to administer medicines using a
PSD, those delegating the duty must
ensure that the healthcare assistants
are trained and competent to do so
safely. PSDs must be supported by a
practice protocol.
Training
MPS has found that many practices
are struggling to source training for
their staff. In many areas the transition
from PCT to CCG is still in progress
and practices have found that training
that was previously provided by the
PCT is not provided by the CCG.
Of the practices that we visited to
undertake a CRSA, 88.9% of those
practices had issues with training or
training needs outstanding.
Nurses must maintain their
registration by meeting the post
registration and practice (PREP)
standards set by the NMC.5 However,
the NMC is in the process of
reviewing and updating the standards
for the maintenance and renewal of
registration. This will form the basis of
their approach to revalidation which
will be launched later in 2014. A
portfolio of training is recommended
Patient Specific Directions (PSD)
The changing role of nurses has
led to more work being allocated to
healthcare assistants. MPS has found
that healthcare assistants increasingly
undertake the administration of flu and
B12 injections. If a healthcare assistant
is required to administer medications
this must be done using a PSD.
The NMC state that a PSD “is a
written instruction from a qualified and
registered prescriber for a medicine
including the dose, route and frequency
or appliance to be supplied or
administered to a named patient.”4
The PSD must include:
■■ Name of patient and/or other
individual patient identifiers
■■ Name, form and strength of medicine
(generic or brand name where
appropriate)
■■ Route of administration
■■ Dose
■■ Frequency
■■ Start and finish dates
■■ Signature of prescriber.
The employer, which in general
practice is typically the GP partners, is
responsible for ensuring that staff are
© JIM VARNEY/SCIENCE PHOTO LIBRARY
C
to help nurses keep up to date, and
employers have a duty to support
staff to meet their training needs.
Training should include:
■■ Annual mandatory updates training
such as CPR, safeguarding, health
and safety, fire safety and infection
control
■■ Reflective practice
■■ Individual learning needs identified
at appraisal
■■ Personal development plan.
Nurse indemnity
From October 2013 indemnity became
a mandatory requirement for all nurses
registered with the NMC.6 Many
nurses working in NHS trusts will be
covered by their employer, however
for nurses working in general practice
this is not always the case. Practice
nurses and nurse practitioners have
an obligation to ensure that adequate
indemnity arrangements are in place.
Summary
In the high-pressured busy
environment that is general practice,
it is imperative that all members of
the practice team adhere to protocols
and are trained sufficiently in their
role to enable them to continue to
practise safely.
REFERENCES
1. Clinical Risk Self Assessments for GP Practices
– www.medicalprotection.org/uk/educationand-events/clinical-risk-self-assessmentsfor-GPs
2. R
oyal College of Nursing. Patient Group
Directions: guidance and information for nurses
(2004) – www.rcn.org.uk/__data/assets/
pdf_file/0008/78506/001370.pdf
3. Nursing and Midwifery (2010) Standards for
medicines management – www.nmc-uk.
org/Documents/NMC-Publications/NMC-
Standards-for-medicines-management.pdf
4. National Institute for Clinical excellence,
Good practice guidance for PGD’s. August
2013 – www.nice.org.uk/media/3A5/A4/
GPG2Guidance_020813.pdf
5. N
ursing and Midwifery Council: PREP standards.
– www.nmc-uk.org/Registration/Staying-onthe-register/Meeting-the-Prep-standards
6. Nursing and Midwifery Council : Professional
indemnity – www.nmc-uk.org/Registration/
Professional-indemnity-insurance
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
12 | MEDICOLEGAL
MEDICOLEGAL | 13
M
the tragic outcome of this case and
her professional confidence was
shaken to the extent that she needed
to have several weeks off work.
However, the medicolegal sequelae
of the incident were not resolved for
a further two years. Mary was in a
category of MPS membership that
entitled her to request assistance in
relation to these matters.
Inquest
Emily’s death was reported to the
coroner and they instigated a police
investigation into the circumstances
surrounding Emily’s death. Mary
underwent the harrowing experience
of being interviewed under caution
by the police, supported by an MPS
instructed solicitor. The police did
not pursue any criminal charges
in this matter, but Mary was called
to give evidence at the coroner’s
inquest. The coroner returned a
verdict of natural causes, but wrote
to the practice asking that they
review and amend their managing
minor illness protocol.
NMC action
The family made a complaint about
Mary to the NMC. The council did
not take any action against Mary
on the basis that she followed the
(albeit flawed) protocol.
Civil claim
The family pursued a claim in
negligence against the practice.
Given the concerns about the
protocols, the claim was settled on
behalf of the practice by MPS.
© JIM VARNEY/SCIENCE PHOTO LIBRARY
ary had been a practice nurse
for four years at Green Surgery.
After a discussion with the senior
partner, Dr D, it was decided that
she would undertake a course in
the management of minor illnesses.
Mary completed the course and
started to undertake her own minor
illness clinics, working in accordance
with protocols adopted from a
neighbouring practice and nominally
under the supervision of Dr D.
One busy Monday morning Mary
saw Emily, a 21-year-old female who
presented with a history of vague
lower abdominal pain, loose motions
and malaise. Mary made a diagnosis
of gastroenteritis and advised Emily
to take analgesia, fluids and sent off
a stool sample.
In the early hours of Tuesday
morning Emily developed severe
abdominal pain and collapsed. An
ambulance was called, but despite
the best efforts of the paramedics
Emily was pronounced dead upon
arrival at the emergency department.
A postmortem examination
confirmed the cause of death as
haemorrhage from a ruptured right
tubal pregnancy.
Unfortunately the protocol that
Mary was following did not mandate
the following:
■■ Assessment of pulse and blood
pressure
■■ An abdominal examination
■■ An exploration of the patients’
menstrual and contraceptive
history
■■ A pregnancy test.
Naturally, Mary was devastated at
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
taking action on pathology results.
These are particularly risky for locums
because of your unfamiliarity with
patients. If in doubt, you should carefully
explain your reasons for declining to
sign prescriptions or, if time permits,
you should negotiate an allotment of
time to complete the task safely in
order to familiarise yourself with the
patient’s medical record. A doctor under
time pressure is more likely to make
mistakes, so it’s important that you
protect yourself and try to agree your
terms and conditions ahead of your shift.
There is always a risk factor with
home visits in a new practice. If you
haven’t properly negotiated the session
structure with the practice, home visits
may be a surprise factor in a shift. If
you are aware of the visit, especially
in advance, you should find out as
much as possible before attending
the patient, in order to avoid mistakes.
Personal safety is also important, so
if you are travelling by foot after dark,
think about the steps you would take
to remain safe.
Dr Ishani Patel at Network Locum
discusses how to mitigate the
everyday risks that locum GPs face
W
ith the ability to cover shifts at the last minute and
provide continuity when permanent staff are absent,
locums are an essential resource.
However, the highly flexible nature of the job as a locum,
which usually involves working in an unfamiliar environment
and with different people each day, can present you with a
number of challenges. It exposes you to risks which you need
to manage with each assignment in order to get the best
possible result for yourself, your patients and the practice.
Risk management is all about thinking ahead, expecting the
worst and having a plan. So what are the common risks GP
locums face and how can you reduce them?
Different IT systems
The lack of information
Any member of staff is likely to perform below their best if
they are unfamiliar with their surroundings, so as a locum
getting as much information as possible before the shift
starts is highly advisable. Not all practices and hospitals have
adequate arrangements for inductions of locums and due to
the nature of the job and where they are available, they are
likely to differ from one practice to another.
Should a practice or hospital provide you with an information
pack, read it as soon as possible. If you are unclear on anything,
ask so you have everything you need ahead in preparation for
your shift. The information pack should include emergency
contacts, intelligence of local services and pathways as well
as detail regarding practice formularies, prescribing incentives,
referral protocols, primary care investigations and local
community clinics. Locums demanding a thorough induction
will eventually lead to better common practice so it’s important
that you push for as much detail as possible.
This is particularly important because as a locum you will
usually be expected to cover short-term absence and are
likely to work out of hours. Without up-to-date information,
the chance of putting patients at risk increases, as simple
tasks such as blood tests or ultrasound scans can’t be
performed. Don’t throw yourself blindly into the shift.
If you get into an at-risk situation, determine what caused
the situation and how you can prevent it from occurring in
the future. Speak to the relevant person and ensure action is
taken on both your parts where appropriate.
Miscommunicated expectations
Every practice team will have different expectations from
their locums. To avoid any misunderstanding, you need to
understand your expected remit before beginning work. There
are tasks and duties that you understandably may not feel
comfortable with, such as signing repeat prescriptions and
© JIM VARNEY/SCIENCE PHOTO LIBRARY
Case study
How to mitigate
the risks that
locum GPs face
Different practices and hospitals
work with different medical computer
packages, so as a locum you can find
yourself using up to three different
computer programmes in a single
week. This can be risky as it increases
the likelihood of making a mistake.
For example, giving a prescription to
a patient and then entering the details
onto someone else’s record could have
devastating consequences. Familiarise
yourself with the technology and
procedures before you start.
Any patient information obtained
during the shift is confidential and
must be treated with due care. Not
being accustomed to the practice’s
IT systems can lead to a danger of
the information being accessed by
unauthorised individuals. To ensure that
all information stays protected, make
sure that you keep any passwords safe
and log off immediately after you finish
using the computer, even if you are
familiar with the system. Wherever you
work and no matter for how long, you
need to adhere to the requirements of
the Data Protection Act 1998.
Accurate and detailed
handovers
else. Where you aren’t present to check
that any urgent actions have been carried
out, it’s critical that handover notes are
accurate and detailed. For this reason,
be wary to consult carefully and efficiently
with new patients and document detailed
clinical notes. When it comes to handling
patient complaints, these records will
help guide how well the complaint is
processed and managed.
You should Read code rather than
text to ensure that ‘problems’ remain
active and feature on the problem list
and summary pages. Read codes
for referrals adheres to best practice
recommendations. The more detailed
the documentation, the easier it is to
look back and recall events, making
the whole process easier and safer
for all parties involved, including when
handling complaints.
Training and development
The majority of locum GPs do not
hold permanent posts anywhere else.
As a result, you need to be mindful of
ensuring you are up-to-date with the
latest training opportunities.
You are also at risk of professional
isolation as you spend a lot of time
working on your own. There are various
GP peer groups that invite locums to
share clinical and practical problems.
Educational or CPD events such as
child safeguarding, vulnerable adult
safeguarding and clinical topics relevant
to primary care, also provide support for
locums and assist in providing evidence
for appraisals and for revalidation.
It’s worth bearing in mind that there
are various online forums where
locums can network with other GPs
Pictured right: Dr Ishani Patel
For more information on Network Locum
visit: www.networklocum.com
and locums. By making the most of the online community
and adhering to the RCGP Social Media Highway Code, you
can ensure that you have an appropriate support system,
can swap experiences and share best practice. By taking
these steps, you will be in a better position to avoid risk and
ensure a positive experience for yourself, your patients and
your practices.
Free high quality CPD sessions and resources can vary
from webinars, such as Simon Wade’s Webinars, to the
traditional lecture-based meetings. Network Locum’s
calendar feature is an example of a great tool for finding
essential CPD events in your area.
Working as a locum can bring great variety to your
career, but with it come challenges and responsibilities,
especially when dealing with people’s lives. However, many
risks that locums face can be prevented if you have good
communication channels with practices and hospitals. And
remember – it really is worth taking time to ensure that you’re
ready for your shift before it starts.
Locums demanding a
thorough induction will
eventually lead to better
common practice so it’s
important that you push for
as much detail as possible
Meticulous record-keeping is essential
for a safe and effective transfer of
information. After all, the next doctor the
patient sees will most likely be someone
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
14 | CAREERS
CAREERS | 15
CORE SKILLS SERIES
Clinical Risk Self Assessments
In this series we explore the key risk areas in general practice
AT A GLANCE
Prescribing can be a risky business, especially when prescribing for
different kinds of patients such as older people or children who can be
particularly vulnerable. Charlotte Hudson talks about the risks and what
you can do to make sure you avoid them.
F
rom over-prescribing, transcribing
incorrectly to new charts and
prescribing for the wrong patient, to
incorrect dosages, interactions and
allergies, prescribing is fraught with
complications. It is imperative that
you have a good knowledge of the
pharmacology and the legislation
surrounding drugs, and the trust
protocols and controlled drug routines
– if unsure, ask.
The GMC’s Good practice in
prescribing and monitoring medicines
and devices (2013)1 says: “You must
prescribe drugs or treatment, including
repeat prescriptions, only when you
have adequate knowledge of the
patient’s health, and are satisfied
that the drugs or treatment serve the
patient’s needs.”
Four out of five people aged over 75 years
take at least one medicine, and 36% of
this age group take four medicines or more
two thirds of these being preventable.2
Whether prescribing errors result
in harm to patients depends on a
number of factors, but certain patients
are at particularly high risk and it is
important to be aware of the drugs
that are commonly associated with
morbidity in general practice.
Risks associated with medication
errors are particularly high in the
following groups of patients:
■■ the old, particularly when frail
■■ those with multiple serious
morbidities
■■ those taking several potentially
hazardous medications
■■ those with acute medical problems
■■ those who are ambivalent about
medication taking or have difficulty
understanding or remembering to
take medication.
Therefore, in these patients, it is
important to take particular care when
first prescribing, to prioritise medication
review, and to check purposefully for
communication issues.
Older patients
The guidance also states that you
are responsible for the prescriptions
you sign and your decisions and
actions when you supply and
administer medicines and devices
or authorise or instruct others to do
so. You must be prepared to explain
and justify your decisions and actions
when prescribing, administering and
managing medicines.
A systematic review in 2009, which
focused on UK studies, found a
prescribing error rate of around 7.5% and
showed that around one in 15 hospital
admissions are medication related, with
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
Four out of five people aged over
75 years take at least one medicine,
and 36% of this age group take four
medicines or more.3 This increases the
number of potential drug interactions,
and increases the chance of side effects
and problems taking them correctly. The
ageing body can be more susceptible
to the side effects of medicines.
What can you do to help?
■■ Help
older patients with the
practical aspects of drug taking –
reminder charts, compliance aids
(eg, a medication organiser) and
specially written instructions. The
physical effects of ageing, such as
arthritis and failing eyesight and
memory, can cause issues for older
people in taking medicines the way
you intended.
■■ Try to keep their drug schedule as
simple as possible. When starting
a new drug, ensure that the dose is
in keeping with the recommended
starting dose for older patients.
■■ As most prescriptions for older
people are repeat prescriptions,
regular review is essential.
■■ Monitor patients for side-effects
of medications – this can help to
identify problems before they result
in serious patient harm.
The most important effect of age on
medication is a reduction in renal
clearance. Many older patients
therefore excrete drugs slowly and
are highly susceptible to nephrotoxic
drugs. This effect may be exacerbated
by an acute illness, particularly one
that causes dehydration.
Children
Children have a very different
response to drugs. Special care
is needed in ensuring the drug
prescribed is appropriate and that the
correct dosage is given, especially in
the neonatal period.
This is particularly true for drugs that
are started in secondary care. The
BNF for Children4 provides practical
information on the use of medicines
in children of all ages from birth to
adolescence and, in 0–18 Years:
Guidance for all Doctors,5 the GMC
states you should be familiar with this.
Adverse drug reactions
Adverse drug reaction profiles in
children may differ from those seen in
adults. You should report suspected
drug reactions to the Medicines and
Healthcare products Regulatory
Agency (MHRA), even if the product
is being used in an off-label manner
or is an unlicensed product. The
identification and reporting of adverse
reactions to drugs in children is
particularly important because:
■■ The action of the drug and its
pharmacokinetics in children
(especially in the very young) may be
different from that in adults.
■■ Drugs are not extensively tested in
children.
■■ Many drugs are not specifically
licensed for use in children and are
used ‘off-label’.
■■ Suitable formulations may not be
available to allow precise dosing in
children.
■■ The nature and course of illnesses
and adverse drug reactions may
differ between adults and children.6
The most common risk was uncollected
scripts, with over 52% of all the practices
visited having this problem, followed by over
49% having repeat prescribing policy issues
– either they didn’t have a policy in place, the
one they have has insufficient detail, or the
one they have is not adequate.
Prescriptions should clearly identify the
patient, the drug, the dose, frequency,
route of administration and start/finish
dates, be written or typed and be signed by
the prescriber. Take care that the correct
information is typed up/written down.
You should ensure that you know as much
If a substance misuser attends in
relation to another matter, you should
have a clear strategy if they request
a prescription. They will be familiar
with the system, can have a highly
plausible reason why a prescription is
needed, and be very persistent. There
should be firm boundaries for these
patients – they will probably be under
an agreed contract for their treatment –
so understanding the procedure in the
practice will help you to deal with them.
about the patient as you can, for example,
being aware of and documenting a patient’s
drug allergies.
The most common problems with
communication occur between the doctor
and patient, but there are also major issues at
the interface between primary and secondary
care – good handovers require good
leadership and communication.
You should ensure you are familiar with
current guidance from the British National
Formulary (BNF). It is accessible online if your
hard copy goes walkabout.
Verbal prescriptions are only acceptable in
emergency situations and should be written
up at the first available opportunity. Particular
care should be taken that the correct drug and
dose is used.
Prescribing diamorphine, dipipanone
and cocaine for addicts can only be
done with a special licence. These
and other Schedule 2 drugs must be
prescribed on a particular form (which
one depends on which country you
are in – check the BNF for details).
Read more on safe prescribing in our
factsheet: Safe prescribing: www.
medicalprotection.org/uk/englandfactsheets/safe-prescribing
Substance misusers
There are 197,110 adults in contact
with NHS treatment services,
according to the National Treatment
Agency for Substance Misuse.7 Many
practices will register substance
misusers for their primary healthcare
needs, but leave treatment of
their addiction to the local drug
dependency unit. Others may get
more involved, offering prescribing
services, for example. Find out what
the arrangement is in your practice.
REFERENCES
1. GMC, Good Practice in prescribing and monitoring medicines and
devices (2013):
2. NPC, 10 top tips for GPs: Strategies for safer prescribing (2011):
www.npc.nhs.uk/evidence/top_10_tips/top_10_tips_for_GPs.php
3. Department of Health, Medicines and Older People (2001):
http://webarchive.nationalarchives.gov.uk/20130107105354/
http://www.dh.gov.uk/PublicationsAndStatistics/
Publications/PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_
ID=4008020&chk=cC38JM
4. B
ritish National Formulary for Children: www.bnf.org/bnf/index.htm
5. GMC, Good Medical Practice (2013), 0-18 years: guidance for all
doctors: www.gmc-uk.org/guidance/ethical_guidance/children_
guidance_index.asp
6. Prescribing for Children: www.patient.co.uk/doctor/prescribingfor-children
7. Public Health England, National Treatment Agency for Substance
Misuse, Drugs and alcohol: www.nta.nhs.uk
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
© MONKEYBUSINESSIMAGES/ISTOCK/THINKSTOCK
Prescribing
Clinical Risk Self Assessments (CRSAs)
conducted by MPS in more than 100 general
practices in the UK in 2013 revealed that over
95% faced risks related to prescribing.
16 | CAREERS
PAGE/SECTION CAREERS
HEADING | 17
CORE SKILLS SERIES
The National Prescribing
Centre (NPC), in 10 Top
Tips for GPs – Strategies
for safer prescribing,
provides ten tips for
safer prescribing:
Case study – An unfortunate prescription
rs H was a 35-year-old teaching
assistant who also had two
school-aged children. She was obese
with a BMI of 40. In 2006, she had
seen Dr G with left knee pain. Dr G
recorded that on examination her knee
was tender over her medial joint line
but was otherwise stable. He initially
prescribed diclofenac and advised her
to lose weight.
Shortly after, Mrs H returned to see
Dr G. She still had knee pain but had
also developed epigastric pain. Dr
G noted her recent diclofenac use,
realised the link and advised her to
stop taking it immediately and return
in a week if her epigastric pain was not
settling. Dr G recorded in the free text
of her consultation notes that Mrs H
had probably had gastrointestinal side
effects to a NSAID but he did not code
this as an adverse reaction on her
problem list.
Mrs H’s epigastric pain did settle
and it was seven months before she
was next seen with ongoing aching
in her left knee, which was giving her
sharp pains when she bent down
to talk to the children at school. Her
weight was once again discussed and
she was referred for physiotherapy.
Mrs H was next seen by Dr J, a
locum, with depressive symptoms in
late 2009. Fluoxetine was prescribed
along with a referral for cognitive
behavioural therapy. Mrs H felt better
as the weeks and months passed but
then her mother died and she became
wary of stopping her fluoxetine, fearing
a relapse of her depressive symptoms.
She remained on fluoxetine with
two monthly reviews by Dr G. The
fluoxetine was issued on each
occasion as an acute prescription for
two months and did not appear on
her repeat medication screen on the
practice computer system.
In January 2011, Mrs H injured her
back while leaning forward to help a
child put on a coat at school. After one
week of severe pain, she consulted Dr
W, a locum GP. Dr W noted that Mrs
H was in distress with pain, was not
able to work or sleep and was having
difficulty caring for her children. He
recorded that she was not responding
to over-the-counter painkillers.
Dr W checked her problem list and
repeat medication screen, both of
which were empty, and concluded
that other than obesity, she was
an otherwise fit 35-year-old. Dr W
prescribed naproxen with co-codamol,
referred Mrs H for physiotherapy and
signed her off work for two weeks. He
failed to note past history of dyspepsia
and did not document any warnings.
Mrs H saw Dr G ten days later. Her
back pain was improving but she was
not yet ready to return to work, was still
requiring analgesia and was running
out of medication. Dr G advised her
to stay off work and issued more
naproxen and co-codamol.
Four days later Mrs H was admitted
with epigastric pain, coffee ground
vomiting, and melaena. While in the
emergency department waiting to
be seen by the medical on-call team,
she had a large haematemesis and
was taken for urgent endoscopy.
Endoscopy revealed a large gastric
ulcer but endoscopic intervention
failed to control the bleeding and she
required emergency laparotomy and a
transfusion of five units of blood.
Postoperatively she was very unwell
and was returned to theatre with
recurrent bleeding. She then spent
two weeks on ITU. Unfortunately, her
recovery was further complicated by a
severe wound infection and she spent
another three weeks in hospital. It was
a further four months before
she felt fully fit and able to
return to work and fully care for
her children without extensive
■■ It is important to keep in mind that all drugs, even those we
family support.
prescribe regularly, might be dangerous to certain patients.
The large ulcer was
■■ When repeating prescriptions by a previous doctor, it is
attributed to NSAID use in a
important to review indications, interactions with other
patient who had previously
medications and most importantly contraindications.
experienced dyspepsia
■■ It is important to record adverse medication reactions
whilst on NSAIDs, her risk
in a way that will be easily displayed for future reference.
being further increased by
In this case, the adverse reaction was buried away in a
concurrent use of an SSRI.
consultation note from five years previously but had not
She made a claim against Dr
been coded as a problem that would be prominently
G and Dr W. The case was
displayed on the patient’s problem list or prescribing notes.
settled for a moderate sum.
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
With Dr Mahibur Rahman from Emedica
1. Keep yourself up-to-date in
your knowledge of therapeutics,
especially for the conditions you
see commonly
A.Diamorphine
3. Before prescribing, make sure
you have all the information
you need about the drug(s) you
are considering prescribing,
including side-effects and
interactions
E.Pethidine
5. Check computerised alerts
in case you have missed an
important interaction or drug
allergy
6. A
lways actively check
prescriptions for errors before
signing them
7. Involve patients in prescribing
decisions and give them
the information they need in
order to take the medicine
as prescribed, to recognise
important side-effects and
to know when to return for
monitoring and/or review
8. Have systems in place for
ensuring that patients receive
essential laboratory test
monitoring for the drugs they
are taking, and that they are
reviewed at appropriate intervals
Learning points
1. W
hich of the following drugs is listed
under Schedule 1 of the controlled
drugs regulations 2001?
2. Before prescribing, make sure
you have all the information
you need about the patient,
including co-morbidities and
allergies
4. Sometimes the risks of
prescribing outweigh the
benefits and so before
prescribing think: ‘Do I need to
prescribe this drug at all?’
© SPOTMATIK/ISTOCK/THINKSTOCK
M
Sample AKT questions
on prescribing
9. M
ake sure that high levels of
safety are built into your repeat
prescribing system
10. Make sure you have safe
and effective ways of
communicating medicines
information between primary
and secondary care, and
acting on medication changes
suggested/initiated by
secondary care clinicians.
B.Methylphenidate
C.Mescaline
D.Cocaine
The correct answer is C: Mescaline. Schedule 1
controlled drugs do not have any recognised medicinal
use. They are not usually available in general practice
and are restricted to licensed parties for research use.
Other Schedule 1 drugs include coca leaf (but not
cocaine which is Schedule 2), cannabis, and lysergide
(LSD). All the other drugs mentioned in this question
are Schedule 2 drugs.
2. W
hich of the following statements
does not apply when prescribing drugs
other than temazepam that fall under
Schedule 2 of the Misuse of Drugs
Regulations 2001?
A.They cannot be prescribed on repeat
prescriptions or under repeat dispensing
schemes.
B.Patient’s details must be written so as to
be indelible.
When prescribing Schedule 2 and Schedule 3 drugs
(with the exception of temazepan) the following details
must be included and written so as to be indelible.
■■
he patient’s full name, address (“no fixed abode
T
acceptable”), and age
■■
he patient’s NHS number or in Scotland the
T
Community index number
■■
he name and form of the drug, even if only one
T
form exists
■■
he strength of the preparation and the dose to be
T
taken
■■
he total quantity of the preparation, or the number
T
of dose units, to be supplied in both words and
figures
■■
ignature of the prescriber (must be handwritten)
S
and date (date can be printed)
■■
ddress of the prescriber (practice or hospital
A
address)
Controlled drugs under Schedule 2 include
diamorphine, morphine, pethidine, glutethimide,
oxycodone, methadone and cocaine.
3. The PRACtICe study commissioned
by the GMC looked at prescribing and
monitoring errors in general practice.
What proportion of prescriptions
studied contained either a prescribing or
monitoring error?
A.1%
B.2%
C.3%
C.The patient’s full address must be
provided, “no fixed abode” is not
acceptable.
D.4%
E.5%
D.The form of the drug is required even
where there is only one form available (eg,
tablet/liquid).
E.They cannot be prescribed without
the patient’s NHS or Community Index
number.
The correct answer is D: The patient’s full address
must be provided, “no fixed abode” is not acceptable.
This is a tricky question as it is negatively framed – it
asks for the statement that does NOT apply. If the
patient is homeless “no fixed abode” is acceptable as
the patient’s full address.
The correct answer is E: 5%. The PRACtICe study
looked at 6,048 unique prescription items for 1,777
patients. The research found that 1 in 20 (5%) of
prescription items contained either a prescribing or
monitoring error, affecting about 1 in 8 patients. Most of
these were minor, or of moderate severity, with less than
1 in 550 (0.18%) of all prescribed items containing an
error considered to be ‘severe’. Factors contributing to
these errors included inadequate training in prescribing,
distractions and poor use of existing IT solutions for
safer prescribing. Full details of the study are at www.
gmc-uk.org/Investigating_the_prevalence_and_causes_
of_prescribing_errors_in_general_practice___The_
PRACtICe_study_Reoprt_May_2012_48605085.pdf
Dr Mahibur Rahman is the medical director of Emedica,
and works as a portfolio GP in the West Midlands. He is the
course director for the Emedica AKT and CSA Preparation
courses, and has helped hundreds of GP trainees achieve
success in their MRCGP AKT and CSA examinations.
MPS members can get a £20 discount off the Emedica
MRCGP courses. Details of the courses are available at
www.emedica.co.uk
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
CAREERS | 19
©MAKSYM BONDARCHUK / ISTOCKPHOTO.COM
18 | CAREERS
In the Hot Seat
Dr Darach Ó Ciardha
For a busy GP, any tool that can save time and labour is valuable.
Charlotte Hudson chats with Dr Darach Ó Ciardha about the
launch of GPBuddy.co.uk and its benefits for GPs and patients
G
Access the GP Buddy
directory here:
www.gpbuddy.co.uk
Follow @gpbuddy
on Twitter or on Facebook
PBuddy.co.uk, designed by Dr Shane
McKeogh and Dr Darach Ó Ciardha – both
practising GPs themselves – is a free online
medical directory, initially aimed at London and
South-East based UK health professionals,
helping GPs find the private medical
professionals and services they require, at the
touch of a button.
Launched in September 2013, GPBuddy.co.uk
is partnered with NB Medical and is the sister
site of GPBuddy.ie – which was launched in May
2010 and has more than 2,100 members.
Dr Ó Ciardha explains: “Shane and I have
forged a close relationship with Drs Simon Curtis
and Phil Nichols who head up NB Medical,
through their activity in Ireland with the extremely
popular Hot Topics series.
“As a GP, Simon was impressed at what we
had to offer to GPs in Ireland and felt that a
version of GPBuddy in the UK could help some
GPs get to grips with the breadth of private
consultants and services, particularly in the
London area. We spoke to UK GPs about their
needs and realised that a comprehensive and
easily searchable database would be of use,
when seeking to refer a patient for a private
specialist consultation.
“The online directory helps GPs be more
organised, and prevents the scrambling around
in drawers for a number on a piece of paper.” Dr
Ó Ciardha says the team feel that patients benefit
too, through more specific referral choices by
their GP – GPBuddy.co.uk will enable them to
explore the most suitable and convenient options
on behalf of their patients.
GPs can search the comprehensive database
for consultants via their special interests as well
as their location – essentially it will save GPs time.
It is free for both GPs and
consultants to list their profile
on GPBuddy.co.uk, and
consultants can opt to pay for
an enhanced listing should
they choose to do so.
“GPBuddy.co.uk can make
the difference in terms of
preventing you being stuck on
If you’re able to shave a minute or two
off your tasks and if that’s repeated a
couple of times over the course of the
day, there are clear time-saving benefits
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
hold if you’re trying to get through to a hospital,”
says Dr Ó Ciardha. “You can get the information
in a couple of seconds as opposed to two or
three minutes. If you’re able to shave a minute or
two off your tasks and if that’s repeated a couple
of times over the course of the day, there are
clear time-saving benefits.”
The website has taken off well so far, with more
than 300 members – and it only launched four
months ago. Dr Ó Ciardha says this number is
growing every day.
Protecting children is something that we all must play
a part in, writes Professor Sir Peter Rubin
C
Rather than setting up
separate Facebook and
Twitter accounts for UK
GPs and Ireland GPs, the
Facebook and Twitter
accounts now cater to
both the UK and Ireland
Educational material
NB Medical (www.nbmedical.com), led by Dr
Simon Curtis, an Oxford-based GP, run the ‘Hot
Topics’ GP Update course at multiple UK-wide
locations every spring and autumn. NB Medical
take the work out of keeping up-to-date and
reviewing all the latest journal evidence and
guidelines on various GP-related topics, and
present the material in an easily digestible
format, which counts towards the annual CPD
requirements for appraisal.
Dr Ó Ciardha says: “We have added other
useful features to our platform in Ireland,
including discussion forums, an events section
and educational resources including consultantled video tutorials. As is the case in Ireland, we
will listen to the feedback given to us by our UK
GP members and add more functionality if there
is a demand for new features.”
As well as managing the GPBuddy websites,
Dr Ó Ciardha is a lecturer in general practice,
Assistant Director on the Trinity College Dublin/
HSE GP Training Programme, and a GP.
Since 2003, he has been heavily involved with
representative and academic activity in Irish
general practice. So how does he juggle all of
his jobs? “With multiple interests good planning
is essential; the best advice I’ve ever had was
to keep a list of things to do. I have a scrappy
A4 pad I bring everywhere with me!” says Dr Ó
Ciardha.
There are currently eight people working on the
website, and the team ensure that data is up-todate and that they are there to help troubleshoot
any issues any of their members encounter.
Helping doctors to keep
children and young people safe
HOT TOPIC
Tweet, Tweet
Rather than setting up separate
Facebook and Twitter accounts
for UK GPs and Ireland GPs, the
Facebook and Twitter accounts now
cater to both the UK and Ireland,
which the team believe, particularly
with Twitter, could be a very
interesting focal point, enabling UK
and Irish GPs to interact.
“The important role that social
media plays in the dissemination
of information cannot be
underestimated,” says Dr Ó Ciardha.
“Some commentators have suggested
that 2014 will be a tipping point, where
for the first time, the majority of medics
will be internet-savvy.”
Still to come
The GPBuddy.co.uk team are
exploring ways of using the
connections they build between
healthcare professionals to improve
the actual referral process, particularly
in the area of secure electronic referral.
“It’s good to be a part of the
conversation that’s happening
amongst healthcare professionals and
people who are interested in medicine
generally,” says Dr Ó Ciardha.
hild protection is a difficult area of
practice, complicated by uncertainty
and emotional challenges. As such, it’s
understandable for those doctors who
aren’t paediatricians to breathe a sigh of
relief that it’s not something they need to
worry about unduly. But, if it’s a principle
we all believe in, it’s also one we must all –
whether we work directly with children or
not – play a part in ensuring. That’s why the
GMC provides detailed guidance, available
on our website, aiming to provide clarity
and reassurance to doctors navigating
this complex landscape. We know from
our Regional Liaison Service, which works
with doctors at a local level, that doctors
are keen to discuss this area of practice, to
understand their responsibilities – and how
to apply them.
The guidance makes it clear that all
doctors, whatever their specialty, have a
duty to raise concerns if they think that
a child or young person may be at risk
of serious harm. This
also applies if the
concerns are
about an adult
patient they
feel may be
at risk of
harming or
neglecting
children,
for example
someone with
a chaotic or
dysfunctional
lifestyle.
Even if a doctor has minor concerns,
they should be aware that what might,
on its own, seem too small to trigger an
investigation, could be part of a wider
picture. That picture may only become clear
when a number of people share apparently
minor worries. You must act on any
concerns you have about a child or young
person who may be at risk of, or suffering,
abuse and neglect. If in doubt you should
ask advice from a named or designated
professional or a lead clinician or, if they are
not available, an experienced colleague.
Linked to this, the guidance
re-emphasises the role of good
communication, and working in partnership
in this area – as in all areas of practice.
Appropriate information sharing is at the
heart of child protection, but it can be
hard to know who to speak to, and how to
balance the duty to report concerns and
the duty to preserve patient confidentiality.
The guidance offers examples of who to
contact, sets out what types of information
should be disclosed, deals with the issue
of seeking consent, and highlights the
tests that need to be applied if you’re
considering sharing information without
consent. Even if you don’t have any current
concerns, it’s worth getting to know who to
call should the need arise.
Finally, and crucially, it aims to reassure
doctors that taking action will be justified,
even if their concerns turn out to be
unfounded, provided that they are honestly
held, reasonable and pursued through
appropriate channels. We’re aware that
some high-profile child protection cases
have caused concern, leading doctors to
voice what are understandable worries
over what happens if cases are dismissed,
or if they in turn get reported under fitness
to practise regulations. So we want to
be clear on this: if a doctor follows our
guidance, and acts in good faith, they can
rely on that fact, and on our support.
Child protection is complex. It’s
challenging. But it’s something we can all
play a part in promoting. Our guidance
aims to help all doctors do just that.
Visit www.gmc-uk.org/guidance/ethical-guidance/13257.asp
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
20 | PRACTICAL PROBLEMS
PRACTICAL PROBLEMS | 21
Practice profile:
New repeat prescribing system
Irena Nestorowytsch-Irwin, business manager at Dr Shorten and
Partners, Lisburn Health Centre, launched a new system for ordering
and collecting repeat prescriptions by chemists
V
arious factors contributed to the practice’s
decision to review and change its system for
ordering and collection of repeat prescriptions. Firstly,
an audit of our repeat prescribing protocol showed
that community pharmacies were ordering for nursing
home residents and on behalf of a large number of
patients, which led to increased prescriptions.
The practice was inundated with faxed lists from
chemists received any time of day with no set
collection times; on occasion the chemists would fax
lists and arrive at reception within minutes to collect
items, which left staff no time to process them properly.
There were disputes with chemists collecting scripts
as they often requested items for patients who weren’t
on the original list. A local pharmacy issued one
driver who collected scripts for seven chemists – this
created extra confusion as items were lost in transit.
Phone calls increased from patients and chemists
querying their missing scripts.
In addition, the variable quality of information
on chemists’ lists increased the risk of error; we
experienced issues around legibility, duplication,
missing patient information or drug details.
Secondly, the practice administrative systems were
labour intensive. In addition there was no reliable
audit trail from an admin perspective for any aspect
of the repeat prescription ordering and collection by
chemists. It emerged that processing the chemist lists
had been the responsibility of one receptionist – with
no clear protocols in place, there was often duplication
of effort and difficulties for other staff to follow up on
what needed to be done during periods of absence.
Finally, we introduced the system to fall in line with
new Health & Social Care Board (HSCB) guidance
on prescribing, generating and dispensing repeat
medications, and faxing prescriptions to community
pharmacists and prescription security.
What did we do?
In October 2012 the business manager and two
receptionists visited the Hillsborough Medical Practice
where the practice manager Cathy Pielou and her team
had implemented a new system for chemists, enabling
patients to nominate one chemist to collect their repeat
prescriptions from the surgery. They were impressed
by the key principles of the system and identified
various aspects that could be adapted for our practice.
The GP prescribing lead Dr Louise Sands also met
with our practice pharmacist and a local community
pharmacist and their feedback was consolidated into
proposed changes to the chemist system.
Learning points from the visit were shared with the
practice team and we brainstormed potential areas of
weakness and positive aspects of proposed changes.
Learning points from the
visit were shared with the
practice team and we
brainstormed potential
areas of weakness
and positive aspects of
proposed changes. Some
members of staff were
sceptical and part of the
challenge was to change
their way of thinking
KEY IMPROVEMENTS
NOTED BY THE PRACTICE:
■■ Significant
reduction in the
number of faxed script requests
received from chemists
■■ Significant
reduction in phone
queries from patients and
chemists
■■ System
of scanned prescriptions
provides staff with an efficient,
reliable backup/audit trail for any
queries which are now dealt with
quickly; this has also reduced the
number of missing scripts and
need for reprinting
© MARK THOMAS/SCIENCE PHOTO LIBRARY
■■ No
The practice was
inundated with faxed lists
from chemists received
any time of day with no
set collection times; on
occasion the chemists
would fax lists and
arrive at reception within
minutes to collect items
prescriptions are issued
retrospectively without prior
discussion with a GP
■■ Reduced
time for a prescription
to be ready from 48 to 24 hours
■■ Significant
reduction in amount
of clerical time spent processing
chemist lists
■■ Medication
reviews identified for
patients whose repeat medication
was being ordered by chemist
■■ Positive
feedback from patients
and local pharmacies.
Some members of staff were sceptical and
part of the challenge was to change their way
of thinking.
A small working group consisting of the GP
lead, the practice pharmacist, the business
manager and two receptionists developed
an implementation strategy including a two
month lead in time. This involved:
■■ One standardised system with a clear
timetable for chemist ordering and
collection of prescriptions
■■ A letter circulated to 24 local community
pharmacies with follow up phone calls
from the practice pharmacist regarding
the new system starting in January 2013;
emphasising the HSCB requirement for
patients to order their own repeat scripts
directly from the practice and not from their
chemist except in exceptional circumstances
■■ Consent forms produced for patients to
nominate ONE chemist to collect their
repeat prescriptions from the surgery;
opt-out forms allow patients to change their
mind. All repeat prescriptions they order
are forwarded to that nominated pharmacy
■■ Chemists asked to provide lists for ordering
on behalf of the frail elderly and vulnerable,
or patients at risk of drug misuse. A small
number were reviewed and approved by
the GP lead
■■ Education of patients requesting repeat
prescriptions. Patients notified of system
change at all points of contact with the practice
■■ Audit process implemented for consent
forms returned to the practice, including
read coding and re-configurating the
patient’s medication record for their
nominated chemist
■■ All repeat prescriptions for chemists are
scanned and stored in the clinical system
in a way that is easy to access for everyone
and clearly visible to read, check names
and number of scripts issued
■■ Protected time was set aside for staff
training and refining the system
■■ Clear protocols were produced for each
stage of the new process.
Success of the new system relied on the
whole practice working as a team, especially
within reception as this was now a shared
responsibility and not that of one person.
Going live
Several hundred patients had signed up to
the system by the time it went live in January
2013. We had planned for teething difficulties
during the changeover period, including
patients with complex needs. The GP lead
played a critical role in dealing with patient
and chemist queries and fully supported the
reception staff in dealing with any frustrations
they encountered.
The new chemist collection system has
certainly redressed the balance between
patient safety and patient convenience. More
than 1,800 patients use the service with only
a few patients either opting out or changing
their nominated chemist. The reception staff
acknowledged that teamwork is critical to
the smooth running of the system now that
it is fully embedded. However, inconsistency
in scanning time and errors made by staff
reinforced the need for further training.
Dr Ryan and Partners located within the
same health centre were impressed with
the system that we had introduced and
approached us for support in implementing it
in their own practice.
For more information visit www.drshortenandpartners.co.uk
or email [email protected]
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
22 | PRACTICAL PROBLEMS
PRACTICAL PROBLEMS | 23
RCGP launches new
YOUR VIEWS – CQC INSPECTIONS
Membership by Assessment of Performance (MAP)
We asked our columnists for their
views on CQC practice inspections
Dr Clare Etherington, Clinical Lead for MAP at the RCGP,
discusses the benefits of the new route to membership for
established GPs
Gladiators, are you ready?!
n April 2014, the RCGP is launching a new
version of MAP, to replace iMAP, as a route to
membership of the RCGP for established GPs.
Membership by Assessment of Performance was
born in 2000; so far more than 1,000 GPs have
successfully completed the process and become
full members of the College. MAP has evolved
since its introduction to parallel the introduction
of annual appraisal and revalidation for all GPs.
The new route will be closely aligned to revalidation
so that the work candidates do for MAP can be used
in annual appraisal and revalidation. We have aligned
our criteria to match revalidation requirements,
including patient satisfaction questionnaire, multisource feedback, significant event analysis, quality
improvement activity and evidence of continuing
professional development. For MAP we ask for these
areas to be presented on the MAP templates, which
have been evaluated as highly acceptable by GPs
who have already undergone the process. The MAP
templates can easily be added to the RCGP or other
appraisal portfolios.
The biggest change in the re-launched MAP is
the removal of the compulsory oral examination.
As with iMAP, two assessors (experienced GPs
trained in the process) will review candidates’
submissions and developmental feedback will be
given. Candidates will be given two opportunities
to reflect on the feedback and re-submit their
evidence if necessary. After the final submission,
a Recommendation Panel will be the arbiter
of these marked portfolios and recommend
successful candidates for membership of the
RCGP. For the very few portfolios that have
undergone the process and are not thought to
have reached the acceptable standard, there will
be an opportunity for a face to face discussion
with a small panel of assessors, to discuss any
area(s) not achieving the standard.
This is designed to be a “do-able” process, in
which we are supporting your revalidation without
A sample portfolio, a MAP
Handbook and advice from
previous applicants are all
available on the RCGP website
creating significant additional extra work for you
as a busy GP and, at the same time, providing a
route to MRCGP with all the benefits to you that
the College currently provides.
What does MAP involve?
You will be asked to submit, within a year of
application, a comprehensive portfolio of 13
criteria covering all aspects of your practice. A few
candidates, where the standard required is not
demonstrated in their written work, will be asked
to meet a panel to discuss their submission.
What resources are there to help me?
A sample portfolio, a MAP Handbook and advice
from previous applicants are all available on the
RCGP website. Your local RCGP faculty will be able
to put you in touch with past and current candidates
in your area and may run MAP Study Days. The
MAP office in RCGP Euston Square is there to
answer your queries. If you struggle to find suitable
help in your area we will help you find support.
What do I get from it?
MAP is the only pathway to RCGP membership
for established GPs. Feedback from past
candidates has been strongly positive, describing
direct benefits from the learning, increased
confidence and improved career pathways.
Membership brings with it many benefits including
journal access, courses, online learning and
careers information; and networking opportunities,
including the annual National Conference.
Further information is available on the RCGP website: www.rcgp.org.uk (until the launch
there will be limited materials available) or by contacting the MAP team: [email protected]
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk
The Apprentice columnist Dr Laura
Davison, a GP in Milton Keynes,
writes that the CQC is about service
not qualifications
© ALTRENDO IMAGES/STOCKBYTE/THINKSTOCK
I
You’ve got your stethoscope, your spell checker exempt
sphygmomanometer, your NICE guidelines, your well-thumbed
BNF copy and your patient list. You are ready to do battle in the GP
Arena. Or are you? Do you know what disinfectant you need to mop
up the vomit in the waiting room? Do you know where to find your
practice Safeguarding Protocol? When was the last time you filled
out a yellow drug card for Mrs Simpson and her loosely-associatedwith-her-new-drug “giddiness”?
I, apparently, am therefore utterly unprepared for CQC. This is
what they’re after – not whether you’ve got carpet in your office
or toys in your waiting room. They’re not bothered that you’ve
got an MRCGP certificate on your wall (mine’s still in its roll in my
loft if they do ask for it), this is about service not qualifications.
CQC, as much as we dread their call and imminent descent
upon our practice havens, are here to ensure we deliver care
that meets their standards and stamps out bad practice to
protect our patients. And rightly so. The vast majority of us work
in efficient, clean, well-functioning practices, and now we just
have to prove it. My poor practice manager bored me senseless
with her foot-thick folder on CQC preparation paperwork, but
think of the preparation not as a character defence but an
opportunity to show off. Demonstrate how proud you are to
work for your organisation, and in return, you might actually
learn something new about your practice.
CQC inspections are not about box-ticking that you have a policy
in place, but that all team members are aware of the processes
of others and know where to get information and how to help the
team provide the ultimate service. It’s not good enough to just say:
“I’d ask Jean in reception about that” – what if Jean’s not there?
It might actually be helpful to know about the different
disinfectants and where they’re kept. The number of times I’m the
only health professional at the end of a session leaves the awkward
possibility of leaving a grim present for the cleaner later that night
rather than being helpful to the team and dealing with it myself.
As GPs we need to be on top of what is expected of us,
educate the rest of our practice troops and lead them fully
prepared into the onslaught of questioning if, and when, the
inspector hordes arrive. I better go ask Jean where the bleach is.
CQC: the new religion – Locum columnist
and editor of the British Journal of
General Practice Dr Euan Lawson, says
there is a new deity in town
While locuming recently I noticed a laminated sign above the
monitor telling me to sit up straight. I’m used to the dog-eared
lists of phone numbers, but advice on ergonomics is unusual. I
suspected a higher power was at work. We may have spent nearly
a decade genuflecting to QOF, but there is a new deity in town.
In biblical terms the CQC is more Old Testament than QOF
and GPs may feel that a plague is descending on their house.
The CQC are falling on practices like the Four Horsemen of
the Apocalypse. Only with suits, clipboards and a fetish for
laminated posters.
Nit inspections. Dental inspections. Drain inspections. No
one likes being inspected. Tax inspectors take your money.
Inspections reek of state interference – intrusive and usually
more than a little demeaning. I can’t think of any inspection
without recalling Viz comic’s notorious The Bottom Inspectors.
You can guess their role and we won’t dwell on the Chief
Inspector of General Practice at this point.
In addition, it is presumably only a matter of time before we
see practices hoisting up banners, as seen outside schools,
proclaiming “We are outstanding!” Those surgeries that don’t
make the highest grades are unlikely to unfurl giant posters
declaring “We could do better with the patient toilets!” or “We
got rid of the maggots!”
It’s easy to carp about the CQC, but I was recently asked to
imagine a town where there was only one garage where I was
allowed to take my car. The government pays for the garage, but
doesn’t check on the standard of service they provide for my car.
In the face of this analogy, I paused and grudgingly conceded
that some kind of modest inspection might be reasonable. And
it was hard to argue when it was offered to me by a GP partner
who is spending a lot of time and effort improving the care in his
practice as a response to CQC. I noted wryly that the glass on his
desk was definitely half-full. Probably vodka.
Even locums can do their bit and so I have resolved that I will
keep my lunchtime yoghurt in the staff kitchen and never consider
the temptingly close and reliably cold vaccine fridge. My lunch is
now worryingly near to the senior partner’s science experiment,
but we all have to make sacrifices to appease the CQC gods.
PRACTICE MATTERS | VOLUME 2 – ISSUE 1 | 2014 | www.mps.org.uk