Obstacles to openness

Sometimes, being open with patients when things go wrong is not as easy as you may think, particularly if you are a sessional, says MPS writer Sarah Whitehouse.

Following an adverse event, being open and admitting something has gone wrong is essential to maintain a patient’s trust. Encouragingly, in a recent survey 92% of MPS members said that they felt they are open and honest with patients.1

Yet poor communication and staff attitudes remain the top reasons for complaints in the NHS, and seven out of ten claims involve poor communication.2 Dr Stephanie Bown, director of policy and communications at MPS, says: “This is a strong indicator that what patients want when things go wrong is the truth, an open and honest explanation of what happened and why, and an apology where this is due.”

What complaint?

As a sessional GP, however, this might prove to be particularly challenging. One of the biggest hurdles for sessional GPs is actually being told when a complaint has been made. Sessional GPs often have difficulties in complying with the provisions of the NHS Complaints Procedures because of the differences in their contractual and working arrangements, eg, they are unlikely to have had any input into the drafting of the practice complaints procedure.

Sessional GPs might not be in the loop when it comes to GP partner meetings, where complaints are often discussed, or in the implementation of the practice’s complaints procedure. If you are a locum, you might not be working at the same practice when the complaint comes to light, so you might not be told how the complaint is progressing. Dr David Stewart, senior medicolegal adviser at MPS, says: “Practices should make every effort to contact any locum involved in a complaint and ask for their input.

"It is not enough to just go on the patient’s notes. The doctor involved in the complaint should actively be involved in trying to resolve it.” The Department of Health’s Listening, Responding, Improving: A Guide to Better Customer Care states that the complaints manager (usually the practice manager) should have an open dialogue with both parties involved in the complaint: “Before the report is finalised everyone involved should be given the chance to give their views on what has been said.”3

The locum experience

One locum GP commented: “The main barrier I’ve come across is that practices often don’t tell the locum that they’ve had a complaint. It is so much easier to say to the patient: ‘Oh sorry, it was the locum, but don’t worry, we’ll never book them again.’ The patient is delighted – they won’t have to see the doctor again and they feel their opinion is valued.”

He added: “On the other hand, it’s a huge hassle for the practice to work out which locum it was (if there were several locums in that day and they all had the same username and password), get the notes posted to the locum, chase the locum up, get them to drive in on their free time to talk to the staff or patient, etc.

“These barriers can be resolved by ensuring all locums have unique usernames and passwords and have doorplates and name badges. As all work is booked through the chambers, we have a strict policy that if any practice manager ever says ‘please can we have a locum, but not Dr Smith again’, we will only continue to book locum work if the surgery agrees to talk to Dr Smith about why they don’t want him anymore.”

Responding to a complaint

Locums and sessionals might not have the opportunity to contact the patient to give an open and honest explanation of what went wrong and why, or to demonstrate to the patient that lessons have been learnt to try and prevent the incident recurring.

Poorly handled explanations serve only to compound the harm, distress and loss of trust that has already been experienced, increasing the likelihood of litigation. Information cannot be provided as openly and empathically if it is second-hand. If you are asked to reattend the practice to try and resolve a complaint at the local stage, this will probably be in the form of a fact-finding interview or writing a witness statement.

You should familiarise yourself with the patient’s records and make sure that any statement is factually correct, conciliatory, empathic and (where relevant) includes an expression of regret. You should ask to see a copy of the reply the practice intends to send, to check it is factually accurate, and should not hesitate to contact MPS for advice.

Barriers to openness

There are other barriers to openness as well as not being automatically involved in the complaint process. MPS members highlight time constraints as a key factor in restricting their ability to communicate as effectively as they would wish.

Two thirds of MPS members believe that there is a pervasive blame and shame culture within the NHS – and believe this is difficult to overcome. When a mistake occurs, 70% of doctors said they received limited, or no support, from their organisation, making it difficult to resolve the complaint promptly and accurately.4

MPS believes that a cultural change is what is needed to improve openness. Meaningful, open and honest communication with patients and working in a culture that expects it is more likely to be delivered by doctors committed to transparent working at all levels, rather than doctors forced to report adverse incidents through legislation and a “top down” managerial approach.

By improving communication between GP practices and locums and sessionals, complaints resolution can focus on openness and honesty between the doctor in question and the patient, allowing complaints to be resolved locally and quickly.

Case study: Left out in the cold

Dr A was a member of GoodDoc, a locum GP agency. He was contracted to work at an inner city medical practice for one day to cover unexpected staff absences over a busy holiday period. He saw Miss C, a 35-year-old patient, who presented with severe abdominal pain. He prescribed some paracetamol and told her to come back in a few days if the pain had not subsided.

The next day, Miss C was rushed to hospital with acute pain. On arrival at the emergency department (ED), she was diagnosed with appendicitis. She was rushed to theatre and luckily the procedure was performed before the appendix ruptured.

She complained to the practice about Dr A’s failure to diagnose. The following week, Mrs W, the practice manager, received Miss C’s complaint, logged it and sent it to the GP partners for discussion at their next meeting. They drafted what they believed to be a sufficient response using the patient’s notes. Dr A was not consulted throughout the process and no attempt was made to contact him.

Miss C was invited into the surgery to discuss the response. She was thoroughly dissatisfied. She felt that the details of the consultation were sketchy and the response was very cold and impersonal. No-one was open and honest with her. No-one apologised. Miss C felt that the practice was hiding something and she decided to take the complaint against Dr A further.

Learning points:

  • Practices should make sure the doctor who is the subject of the complaint is involved in responding to the patient’s concerns and drawing up steps to avoid errors in the future.
  • Practices should have a complaints manager (again, usually the practice manager) who can deal with all complaints in the first instance and a responsible person (usually a GP partner) whose role (in part) it is to ensure that the correct procedure is being followed.
  • The complaints manager should make every effort to contact the locum through the relevant agency, giving them adequate notification of the complaint and the right to respond to the complaint.
  • It is a good idea for the practice manager to keep a log of all the locums used at the practice, along with their contact details.

References

  1. MPS/ComRes Survey, An online poll of 541 MPS members in March 2011, which involved GPs, consultants and non-consultant hospital doctors (2011)
  2. Sir Liam Donaldson, World Health Organisation’s “World alliance for patient safety” conference (2004)
  3. Department of Health, Listening, Responding, Improving: A Guide to Better Customer Care (2009)
  4. Ibid 1

Charlotte Hudson

Writer and editor at MPS. MPS’s educational risk management workshops, ‘Mastering Professional Interactions’ and ‘Medical Records for GPs’ provide further information on the risks to patients and doctors when patient care passes between doctors, and on good record-keeping. They are free as a benefit of membership to MPS members too.

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