Failures in safeguarding vulnerable adults can and do result in tragedy and harm to individuals and professionals. It’s a tricky thing for GPs to get right – and vital to focus on.
The case of Joseph O’Hanlon, an alcoholic who was beaten to death in his home after concerns were raised about him being taken advantage of by drinking associates, was one which highlighted the issues around adult safeguarding. While steps taken by authorities in the case were said to have been reasonable and, in some examples, even excellent, the case led to calls for vulnerable adults to be treated in the same way as children at risk of harm. It was felt that had the case involved a vulnerable child ‘there would have been a much greater level of expectation in relation to the actions of professionals’.
A key tenet of safeguarding, both for adults and children, is that it is everyone’s responsibility. And all health care staff, from administrators and receptionists up to GP partners, have minimum standards of competency to meet.
Dr Joy Shacklock, the Royal College of GPs’ Clinical Champion for Good Practice and Safeguarding has said: “Safeguarding adults at risk of harm is a key duty for all who work in healthcare.”
Adult safeguarding: roles and competencies for health care staff
The publication of the Royal College of Nursing’s ‘Adult safeguarding: roles and competencies for health care staff’ in August 2018 was hailed as the first UK guidance to help healthcare staff better protect adults at risk of harm, abuse and neglect.
It was designed to be relevant to all healthcare and social care professionals and outlines to what degree staff at all levels must be proficient in the subject. In addition, it underlines the necessity for ongoing professional development and training within this area.
For ‘Level One’ staff, including receptionists and administrators, the document says there is a necessity to know the signs of possible neglect, harm or abuse and who to contact for advice over concerns. This includes the requirement to be willing to listen to concerns about risk, recognise how personal beliefs, experience and attitudes may influence safeguarding work and recognise how their own actions may impact on others.
‘Level Two’ staff, including GP practice managers, must have increased levels of competency including ensuring action is taken where necessary, including to organise advocacy for the individual where required. There is also a requirement to understand mental capacity legislation relevant to the country of practice, which varies between UK countries.
For staff considered ‘Level Three,’ including GPs, it outlines a comprehensive list of necessary competencies, knowledge and attitudes.
There is a further tier of competency for those in specialist roles including named GPs/doctors for organisations commissioning primary care.
The six principles of adult safeguarding
Six foundation principles of adult safeguarding, set out by the Department of Health, inform how professionals should engage with people at risk of abuse, harm or neglect.
The principles in themselves are open to a certain level of interpretation and highlight the potential for complexity in decision making and the balancing act involved in properly meeting safeguarding requirements.
The premise of the principles is around ensuring safeguarding is something that is done with patients and not to them.
The principles are:
- Empowerment There is a presumption of informed consent and for the patient to be involved in the safeguarding process, desired outcomes and any resulting action
- Prevention There is a duty to ensure help is given to allow patients to recognise what abuse is and pathways to support
- Proportionality A responsibility exists to provide the least intrusive response to the level of risk posed
- Protection This principle hinges around ensuring those who need support and representation to report abuse receive it.
- Partnership It’s necessary to ensure information is only shared to the degree that is helpful and necessary even where consent is obtained and that the patient has confidence in this.
- Accountability Patients need to know who is involved in the safeguarding process and in what ways they are involved.
What constitutes abuse, neglect and harm?
In order to fulfil obligations, GPs and their teams must be alert to the full range of potential abuse, neglect and harm and not constrained in their view of what can qualify as a potential safeguarding issue.
This can include:
- Physical abuse including inappropriate restraint or physical sanctions
- Sexual abuse including all non consensual or coerced acts, sexual harassment and non-contact acts such as indecent exposure and online abuse
- Psychological and emotional abuse inclusive of threats of harm or abandonment, coercion, isolation and unjustified withdrawal of support
- Financial or material abuse including theft, fraud, exploitation or coercion. ‘Cuckooing’ should also be considered, which is where a person’s property is taken over and used for illegal activity, particularly drug dealing
- Neglect and acts of omission inclusive of failing to provide access to appropriate health and social care, necessities of life or the necessary support to access those
- Self neglect as well as basics such as personal hygiene, health and environment. This may include certain behaviours such as hoarding
- Domestic abuse, which may occur within relationships irrespective of gender and is inclusive of coercive and controlling behaviour, female genital mutilation and honour based violence
- Discriminatory abuse unequal treatment due to any protected characteristics
- Organisational abuse may relate to one-off or ongoing failures or practices
- Modern slavery where people are forced to endure a life of abuse, servtitude or inhumane treatment.
An overview: safeguarding vulnerable adults
Adult safeguarding is a complex area of practice with heavy moral, as well as legislative requirements. It is an area that is open to interpretation at many stages, involves a wide client group and can involve many service providers.
The Care Act 2014, does not use the term ‘vulnerable adult,’ instead referring to adults with a care or support need – a reminder that all adults may fall into the category at certain times. A carer may be in need of safeguarding as a result of the pressures upon them or behaviour of their charge. Similarly an individual may become ‘vulnerable’ temporarily due to a specific period of ill health or mental strain.
GP practices must do everything possible to ensure adults at risk are protected via proper and effective training, information and protocols for all staff.
As well as being aware of legislative requirements, GPs may also have additional contractual obligations with commissioners in relation to safeguarding vulnerable adults.
Safeguarding is naturally interlocked with confidentiality, data protection and mental capacity legislation. Certain disclosures are required at certain times according to relevant legislation.
A breach in relation to responsibilities to safeguard vulnerable adults is a legitimate concern and can cause conflict in terms of doctor-patient confidentiality, for example.
For advice on any situation regarding safeguarding vulnerable adults contact us.
At MDS, we’re used to helping GPs to handle complaints and queries when things don’t go to plan. As GPs ourselves, we understand the challenges this job can throw up and we vow to step in with support where and when we can.
Yet, we’re also keen to help GPs by refreshing their knowledge and providing useful tips on what to do if things go wrong.
In this latest post, we’re going to look at significant events and how to react to these. If you’re currently concerned about a significant event and in the midst of dealing with this then don’t hesitate to contact us, otherwise read on for a quick refresher.
The General Medical Council offers a useful definition of a significant event to keep in mind as a GP.
It states: “A significant event (also known as an untoward or critical incident) is any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented.”
The following, therefore, are all examples of significant events:
- The unexpected death of a patient
- A diagnosis that was delayed or missed
- A medication error
- A problem arising from a failure of communication
It’s vital to react swiftly and effectively in order to learn the lessons of a significant event.
Why to react to significant events
Significant events call for a significant response. First and foremost, this is because it’s the right thing to do. As a GP, you want to do your level best to look after your patients – and that means learning lessons and adapting your practices whenever required.
On top of this, it’s also important to bear in mind that:
- The General Medical Council requires you to be open and honest if things go wrong and will expect to see evidence of your reaction if a formal inquiry is needed
- The NHS complaints procedure requires you to learn from incidents
- The Care Quality Commission requires you to assess and monitor the quality of your service provision
The requirements of all of these bodies involve reacting appropriately once a significant event occurs.
How to react to a significant event
So, what should you do to ensure you can react properly to significant events? The answer lies in the system, process and people in your practice. Consider the following:
- Staff training is essential. A GP practice is only as strong as its people. Ensure everyone understands your process and that training and retraining forms part of your schedule.
- You need a simple system in place to make it as easy as possible to report and react to significant events. It’s important to revisit this system on a regular basis.
- Communication is a key part of this system. People need to know who to report issues to and work in an environment where they feel they can report these issues without fear.
- When an event occurs, a report should be made and tis must be completely factual.
- There should be someone overseeing the whole process. This could be the practice clinical governance lead.
- A detailed log of any action taken must be kept.
Significant event analysis: The proactive approach
Significant event analysis involves taking a proactive approach. It’s about using the information accrued during and after a significant event and using it to introduce new measures to try to prevent one from occurring in the first place. It should involve the wider team and be an open and honest assessment of the case in question. This isn’t about apportioning blame, rather it’s a case of answering four key questions:
- What happened?
- Why did it happen?
- What has been learned?
- What has been changed or actioned?
Stick closely to these questions – which are those highlighted by the National Reporting and Learning Service (NRLS) – and ensure you’ve answered them fully before the process is complete.
Nigel Sparrow, Senior National GP Advisor and Responsible Officer for the Care Quality Commission, explained: “SEA should act as a learning process for the whole practice. Individual SEAs can be shared between members of staff, including GPs, and should focus on disseminating learning within the practice.”
He notes that SEAs should:
- Identify key events in individual cases (positive or negative) and use them to learn lessons
- Help to embed a culture of openness and reflective learning
- Promote the team ethic needed after a potentially stressful incident
- Reflect on the good elements of practice as well as the things that went well
- Identify training and career development needs
- Share information between teams
He added that when it comes to CQC inspections: “We want to see evidence of learning from incidents and improving quality. On inspection we look for the impact and learning that has resulted from the SEA. We expect ‘good’ practices to ensure that the learning from SEAs involves the whole team and becomes embedded in everyday practice.”
Significant Event Analysis: Resources
The above should hopefully serve as an introduction or refresher into significant events. We appreciate that this is a topic which you might want to read about in greater depth – and you might well want some resources that can help to ensure you are reacting efficiently and effectively when the moment occurs.
Here we’ve picked out some useful resources to assist you with this:
- This PDF is a great example of an SEA form from NHS Scotland that can be used as a template for your own forms.
- NHS Scotland has also produced this guide, which walks you through the decision making process at each stage, broken down into three key phases.
- There are simple and easy to use forms available from the National Association of Sessional GPs, either as a download or as a Google Drive document.
- This is another great toolkit, from Medical Appraisal Scotland, that was designed for sessional GPs.
- The Royal College of GPs has even produced a toolkit that looks specifically at cancer SEAs – with resources and thematic case studies.
If you want to learn more about significant events and how to react appropriately when they occur, get in touch with our team.
The vast majority of the enquiries we receive at the Medical Defense Society relate to NHS complaints – and this is a key area in which GPs need support.
While all GPs aim for the very highest standards of care it’s a fact of life that not everyone will always be wholly satisfied with their care. Whether fair or not, complaints can occur and you need to know how to appropriately react to them.
While we would always recommend that our members come to us for full support after a complaint, we’re also keen to ensure you have handy information at your fingertips too. With that in mind, here’s a handy refresher to get you up to speed.
GPs and the NHS complaints procedure: What you need to know
The NHS complaints procedure has two basic tiers – one that is more informal entitled ‘feedback’ and the other billed a complaint.
Depending on the severity of the issue at hand, encouraging and engaging with feedback at an early stage can prevent an unnecessary progression to the ‘complaint’ phase.
It makes sense to provide clear opportunities to offer feedback in order to deal early with dissatisfaction and allow action to ensure similar problems can be avoided. Obviously it is in the best interest of both patients and GPs for complaints to be dealt with expeditiously.
The Health Select Committee has stated: “In moving to a culture which welcomes complaints as a way of improving NHS services, the number of complaints about a provider, rather than being an indicator of failure, may highlight a service which has developed a positive culture of complaints handling and it will be important for system and professional regulators alike to be able to identify the difference.”
Complaints can be made directly to the provider or to the commissioning body.
Meeting standards in responding to a complaint
Unsurprisingly, GPs often have concerns around responding to a complaint in terms of accepting or implying liability. However it is important not to delay or avoid acknowledging and dealing with issues as this can inflame matters. A simple and sincere apology can, when appropriate, prevent a complaint escalating.
A thematic review of general practice complaint handling across England said: “GPs can fear liability, litigation and a damaged reputation, which can act as a disincentive to being open and honest, despite a duty to do the right thing.”
Saying sorry need not be an admission of liability and doctors have responsibilities to be open and honest under the duty of candour.
Staff within your practice must be well trained and briefed on how to deal with feedback and complaints and a sensible procedure put in place.
Appropriate advice should be taken in terms of training, procedure development and, where necessary, at the point of a complaint being received.
Requirements must be met in relation to acknowledgement of a complaint, proper investigation, feedback and resolution. In addition, patients must not be treated differently despite their complaint. Your procedure should ensure this point is demonstrable.
A complainant is also entitled to expect appropriate action to be taken in response to the issue they raise.
When and how can a complaint be made
An NHS complaint can be made long after the incident or issue in question as, while there is a time limit, it is broad.
The rules state a complaint should be made: “Within 12 months of the incident, or within 12 months of the matter coming to your attention.”
Even that time limit can be extended.
It is admissible for the complaint to be made by any person appointed by the patient, providing they have their permission that could be a family member, carer, friend or even a local MP. Confidentiality rules still apply.
Advice and liaison services can assist in ensuring complaints are brought in a timely way and may support resolution. Displaying details of local Healthwatch and similar services allows patients to access good quality advice on raising their compliant and providing the necessary information for you to deal with it well.
Escalation of a complaint
If a complaint is not dealt with to the satisfaction of the person who raised it, it may be escalated to the Parliamentary and Health Service Ombudsman.
The ombudsman can make a variety of recommendations but does not have the power to impose those.
It can ask for:
- Action to be taken to put things right
- A decision to be reconsidered if it is lear mistakes were made, the matter was not dealt with fairly or procedure was not followed
- The improvement of services to avoid the same things happening again
The Parliamentary and Health Service Ombudsman should not usually look at a complaint where there is or has been the option for resolution via a legal mode, such as court or tribunal. Discretion can be shown.
How well do GPs do when it comes to handling complaints?
The ‘thematic review of general practice complaint handling across England’ found that whilst 55% of general practices did a good job of complaint handling, 45% were falling short.
The review said: “Most people have far more contact with their GP practice than with any other NHS service, and they are often an individual’s link in to other NHS services. That’s why getting complaint handling right in general practice is so important – it has the potential to make a difference to everybody who uses the NHS.”
The review stated that in 2014-15, the Parliamentary and Health Service Ombudsman completed received 5,086 complaint enquiries about general practice. Of those 696 (14%) were investigated and 32% upheld. This was at the lower end of the uphold rate, with 44% of cases about acute trusts and 33% of mental health, social care and learning disability trusts upheld.
It said GP practices tend to receive 8.5 complaints annually. GPs face the additional challenges of not usually having a specialist team to deal with complaints and the likelihood of a close relationship between the person being complained about and the internal investigator.
Top tips for GP complaint handling
A joint publication from the Care Quality Commission, NHS England, Healthwatch and the Parliamentary and Health Service Ombudsman offers 10 tips to help GPs improve complaint handling in their practices.
It says: “Complaints and concerns are a valuable source of feedback that can help your practice improve its service. Handling them well not only shows patients that you are listening and that their concerns matter, but it can also help to improve your reputation.”
The ten pointers on complaint handling best practice are:
- Show how you have responded to complaints and feedback with a ‘you said, we did’ resource such as a noticeboard
- Invest in training to share experiences of complaint handling and resolution
- Work with the Patient Participation Group, for example to:
- Ensure your complaints policy is clear, easy to understand and fit for purpose
- Actively collect feedback from patients
- Help review comments and feedback
- Be open and responsive
- Clearly explain decisions about care and treatment, following NICE guidelines.
- A genuine apology may prevent an issue developing into a formal complaint
- Acknowledge the value of advocacy services and Healthwatch groups and signpost to them
- Use NHS England’s Assurance of Good Complaint Handling for Primary Care Toolkit
- Ensure a joint approach where the complaint is about another provider too
- Only remove a patient from your list due to and at the time of an incident, not as a result of a complaint
GPs have an unusual relationship with their patients. Together, you might well share moments that are deeply emotional and come to learn details that they’ve shared with no-one else, not even their closest.
That’s part of the job – but it also presents a challenge to GPs. There’s a need for doctors to be able to protect patients – but there are other situations where sharing information might be necessary.
The General Medical Council has drawn up useful guidance for such scenarios. In this post, we take a look at some of the GMC’s advice to give you an understand
GP confidentiality: What the GMC says
There are six key areas highlighted by the GMC when it comes to doctor/patient confidentiality and data.
Education and training
Patients’ data should anonymised for this purpose. If it’s not possible to do so, medical professionals should ask for the patient’s consent. When obtaining this consent, you should be clear about what the information is set to be used for and who will be using it. Patients have to have the opportunity to say no – and shouldn’t feel obliged to take part.
GPs might be asked for information by someone’s employer. Similarly, data on the health of an individual might be requested by an insurance company or sports team. You should only comply with such requests if:
- you’re happy that the patient knows what is being requested and how it’ll be used
- you have seen written consent from the patient
- you only provide factual information that is relevant to the matter
- you offer to show the patient your report or send them a copy
Spread of serious disease
There are some circumstances in which the ‘public interest’ means that health information must be disclosed. The GMC outlines that this could be the case when it comes to ‘serious communicable diseases’. It states: “If you consider that failure to disclose the information would leave individuals or society exposed to a risk so serious that it outweighs the patient’s and the public interest in maintaining confidentiality, you should disclose relevant information promptly to an appropriate person or authority.”
The above scenario demonstrates that doctors have a duty to protect and promote the health of the public as well as their patients. This can also collide with doctor/patient confidentiality when it comes to driving. A driver has a legal responsibility to tell the DVLA if they have a condition or treatment that means they are unfit to drive. Doctors should tell them if they have such conditions and make clear that driving is something that isn’t safe in these circumstances (and, legally, should be reported). However, if they continue to drive when unfit a GP may feel it’s in the public interest to reveal this to the DVLA. Even then, GPs should alert patients that they feel this is necessary and let them know when they have contacted the DVLA.
Gunshot and knife wounds
It’s clearly in the public interest for the police to investigate serious crimes such as those involving gunshot or knife wounds – but doctors need to be careful not to deter patients from coming forward when they need medical assistance too. Again, this is a balancing act. If you feel that your patient and/or others are at a serious risk, you should disclose this to the authorities in a sensitive and appropriate manner.
Some patients choose to publicly criticise their GPs in the media. This can be stressful and frustrating – especially if you feel the details they have given to the press are inaccurate or misleading. However, it’s important to note that this alone doesn’t relieve you of your duty to maintain confidentiality. A public row can undermine a GP’s standing in the eyes of other patients and prolong the issue. GPs are advised to avoid commenting – or sticking to general remarks about their practice.
Any GP who is concerned about confidentiality – whether that’s maintaining this or balancing it against the public interest – should seek support. Contact us if you have a query on confidentiality or any other matter relating to your work as a GP.
The importance of looking after our GPs has never been more vital as more surgeries close, along with a sustained fall in UK GP numbers. What this means, is that highly skilled professionals in our industry are under pressure to see and treat more patients in an already long working day.
Law firm Slater and Gordon took a survey of 200 family doctors and discovered that 80% of these GPs felt they didn’t have sufficient time to properly diagnose patients. 35% of those who took part in the survey admitted they had missed symptoms, while 37% believed they may have prescribed the incorrect course of treatment.
Clinical negligence expert Parm Sahota, from Slater and Gordon, told the Telegraph: “Working in this area of law I already knew GPs were stretched, but the timeframes they are expected to practice within are suffocating.”
Royal College of GPs: ’10-minute appointment not fit for purpose’
Chair of the Royal College of GPs, Professor Helen Stokes-Lampard has responded to this research. Here’s her full statement:
“It has been clear for some time that the standard 10-minute appointment is no longer fit for purpose. As GPs, we want to be able to deliver truly holistic care to our patients after considering all the physical, psychological and social factors potentially impacting on their health.
“But when you consider that very few patients now come to us with just one health-related condition, and that we are increasingly up against the clock in consultations, this is simply not possible and in some cases it could be unsafe.
“We know that GPs and our teams are working under intense resource and workforce pressures and as a result, hard-working, experienced family doctors are burning out, and leaving the profession earlier than they would have done. These must be addressed, not just to keep general practice – and the wider NHS – sustainable, but for our patients’ safety.
“We have called for 15-minute appointments as a standard, with longer for those patients with complex health needs who need it. But with GP workload soaring, falling numbers of family doctors, and patients waiting longer for appointments, we need more resources and an expanded workforce to make these longer consultations feasible – otherwise it will only add to pressures and serve to undermine patients’ ability to access the care that they need.”
Measures regarding longer appointment times are absolutely required to help GPs and it’s important to make it clear that the knowledge and skill of GPs is appreciated by patients across the UK. In response to this research, an NHS spokesperson told the Telegraph:
“The recent GP Patient Survey showed that more than nine in 10 patients trusted their GP, and more than eight in 10 people described their experience at their GP practice as good or better.”
Action needed to help GPs
It’s clearly important to look after our GPs in order for them to look after the health of the community. The call for longer appointment times as standard have been around for some time, but the action required to address this is becoming increasingly urgent. With the previously mentioned surgery closures and fall in GP numbers in the UK, there’s increasing pressure on family doctors across the country.
MDS CEO Rohan Simon said: “As an MDO set up by GPs for GPs, we’re acutely aware that some members of our profession feel under pressure. We’re keen to make sure that GPs get help in these instances and are able to access the correct support if they do make an error.
“If any GP does have a concern, we’d encourage them to contact us. As a nation, we need to look after our GPs so that we keep our skilled professionals in their roles and that they have the help they need to do their jobs to the best standard.”
There’s help at hand if you feel under pressure in your GP role. If you feel you need support, don’t hesitate to get in touch with us by calling 020 8938 3631, or alternatively contact us online here.
GPs are highly skilled professionals but they’re also human beings and that means mistakes in their jobs are possible.
As an MDO set up by GPs for GPs we understand and appreciate this as well as anyone – but we also know the importance of reacting appropriately when something has gone wrong.
In this guide, we’ll take a top-level look at the rules around duty of candour and what they say about the need to act after an error have been made.
What is duty of candour and why was it introduced?
Duty of candour is the legal requirement placed on GPs to be open and honest with patients and their families when something goes wrong that either does or could have caused significant harm. Under this, patients should be told of a ‘notifiable safety incident’ as soon as possible.
Duty of candour was introduced in November 2014 and then extended to GPs the following April and forms regulation 20 of the Health and Social Care Act 2008.
The new regulation came as a response to the Francis Inquiry, which looked into the care given by Mid Staffordshire NHS Foundation Trust. During the inquiry, it emerged that patients had not always been given a thorough explanation by the trust when their care had gone wrong.
The duty of candour was proposed by Sir Robert Francis and later accepted by then health secretary Jeremy Hunt. This is over and above a GP’s professional and ethical duty to be open and honest with a patient.
Duty of candour law: What you need to know
When considering duty of candour, it’s important to understand what is meant by a notifiable safety incident – and what the General Medical Council’s guidance says about reacting to this.
For GPs, a notifiable safety incident is something that, according to the ‘reasonable opinion of the health professional’ either did or could have caused:
• Death (outside of the natural course of an illness)
• Reduced sensory, motor or intellectual function (for 28 days or more)
• Amputation or other changes to the structure of the body
• Psychological harm (for 28 days or more)
• Shortened life expectancy
• Treatment to prevent death or any of the other above outcomes
In Scotland, the process is similar but the ‘reasonable opinion’ needs to come from a healthcare professional who isn’t involved in the incident. Scottish duty of candour comes under the Health (Tobacco, Nicotine and Care etc.) (Scotland) Act 2016.
In England, patients should be notified of the above as soon as possible. In Scotland, the government’s guidance suggests this should be within ten days.
GPs should arrange to meet in person with their patient to share any necessary information and, importantly, to apologise.
An apology is not an admission of guilt
At this point, it’s very important to stress that an apology is not the same as an admission of guilt. GPs should not feel as though they cannot apologise because it will end up costing them in future litigation. Indeed, the NHS Litigation authority states it ‘will never withhold cover for a claim because an apology or explanation has been given’.
GPs aren’t obliged to accept personal responsibility for things that were outside of their control such as a system error. However, the patient does have the right to an apology from the most appropriate team member, regardless of the source of responsibility.
The General Medical Council outlines three clear parts to an apology issued under duty of candour. It should outline:
• What has happened
• What can be done to deal with any immediate harm caused
• What will be done to prevent a repeat in the future
A GP’s apology should be genuine and relies on the individual to judge their own situation. However, the GMC suggests to bear the following in mind:
• Give patients information in a way they’ll understand
• Speak to patients at an appropriate time
• Be considerate with distressing details
• Be personal and properly apologise
• Tell the patient who to contact if they have further concerns
• Record details in a patient’s clinical record
Seek support with duty of candour matters
Hopefully this guide has filled you in on some of the key points to remember about duty of candour. However, if you do find yourself involved in a ‘notifiable safety incident’ then it’s important to remember that you should seek support.
With the Medical Defense Society you have access to our medico-legal advisory team and help with, for example, understanding how to handle an apology in one of the cases outlined above.
If you want to discuss duty of candour or if you wish to find out more about joining MDS, contact us today.