Complaints; The PCT; NCAS; GMC; Revalidation

Dr Eric Saunderson

Medical Director, NHS Barking and Dagenham

Objectives for today

Understand the roles of the following organisations in complaints against GPs:

The Medical Director; the PCT; NCAS; the GMC

Have a clearer understanding of the new agenda of revalidation: enhanced appraisal; 360 degree appraisal; the Responsible Officer

Discuss complaints and their management; consider how to minimise complaints or deal with them in a professional manner

The PCT Complaints procedure

Patients complain directly to the PCT Complaints’ Dept.

The PCT receives between 30 - 50 complaints quarterly

Complaints about staff attitudes are common

Complaints about quality of GP treatment are the most common

Some complaints involve several issues e.g. clinical treatment, pharmacy, attitude, delayed referral, etc

What happens in the Complaints’ Dept?

Sympathetic acknowledgements are sent to complainants explaining the PCT/NHS Complaints’ Procedures

The complainant is asked to agree to the PCT contacting the doctor

The doctor is asked for his side

The doctor’s response is made available to the complainant; this may resolve the issue

If not, the complainant is offered conciliation or referral to the NHS Ombudsman

The Complaints’ Dept

The Medical Director acts as an advisor to the department, usually for clinical grounds but also if there are several complaints against one particular practice

Anonymous complaints arise from time to time. The PCT has an agreed policy with the LMC in dealing with these

Sometimes, the Medical Director will write directly to the GP or may visit

The Ombudsman

Undertakes an independent investigation into the complaint using letters

Both sides are asked to produce statements

The Ombudsman is advised by appropriately qualified clinicians

The findings are made known to the complainant and GP

Many complaints are not upheld against GPs

Note keeping is a common identified issue – let’s discuss

Complaints and the Medical Director

Tend to be more serious

Arise from the Complaints’ Dept; directly from patients or relatives; may arise from the local MPs; are communicated from colleagues – both specialists and GPs; may be brought to the attention of the PCT from the GMC; or other agencies e.g. Adult or Child Safeguarding committees

The Medical Director has a range of options from ‘a quiet word’ to ‘something more coercive’!

The Performance Decision-making Group

A subcommittee of the Governance Group

Has a NED Chair, CE, MD, solicitor, CG, GP

Considers all serious complaints

Provides guidance to the MD for investigations

Investigations tend to be undertaken by an outside agency for more serious complaints

Example 1

A single handed GP with a list of 2,000 visited an elderly patient with abdominal pain. He did not take notes with him. He had only recently been employed in the practice. The patient had a PH of AAA. The doctor was told this by the patient’s daughter. The doctor’s diagnosis was constipation. The patient died shortly after the visit. The daughter complained to the Healthcare Commission. Their investigation showed poor record keeping. The PCT was informed.

What would you do?

Example 2

A mother complained to the PCT that her doctor had seen her one year old son with otalgia. At the end of the consultation, the patient asked the doctor to look at the child’s BCG vaccination site as it seemed swollen. The doctor looked at the child’s arm from some distance and stated it was fine. The next morning the child’s arm was discharging. The patient took her child to a WiC and was prescribed appropriate antibiotics. The mother made a complaint to the PCT stating the doctor was uncaring, had a poor attitude and had not taken the complaint seriously and professionally.

How would you manage this scenario?

Example 3

A single handed GP had an adverse sickness record. He had various periods of sickness, including prolonged periods when a locum allowance was claimed. He employed various locums to run his practice and a series of complaints gradually built up due to the lack of continuity. He returned to work for a short period then went off sick again. He was aged 62.

What thoughts do you have for managing this situation?

National Clinical Assessment Service

Set up in 1995 to provide information and investigation of doctors

Provides a guidance service for PCTs

Suspension of a doctor must be discussed with NCAS first

Have specially trained clinical advisors

A doctor can be referred to NCAS for further investigation in three parts: occupational health; psychological assessment; clinical assessment

Detailed reports provided to the PCT; support, action planning, remediation

The GMC

The national regulator

>80% of complaints referred to it are returned to the PCT for further management

Of the several thousands of complaints, < 20 per year are career threatening

Of those referred by PCTs, or the more serious complaints, screening occurs first. A large proportion are rejected.

The remainder are referred to the Fitness to Practise committee

FTP

Full investigation includes MCG; simulated surgery. Then,

2 days observation of practise similar to NCAS

Detailed report written following GMC guidance in Good Medical Practise: Patient welcome, history taking, problem solving, treatment and management; probity

Appearance at the Panel. Legal representation.

Most doctors found with impairment will have ‘conditions’ placed on their registration and will undergo remediation

Remediation

Tailored to the doctor’s individual needs

Reappearance at the FTP following an appropriate interval

Removal of conditions

Other sanctions

Good time for tea?

Revalidation

Why? ShipmanDame Janet SmithLiam Donaldson’s report ‘Good doctors, safer patients’ 2005Much discussion between the GMC, BMA and Royal CollegesRCGP is the responsible College for GPs, regardless of membershipLook at the RCGP website for more informationwww.rcgp.org.uk

Starts 2011

What does the legislation say?

In order to remain on the Medical Register, each doctor must revalidate every 5 years. This comprises:

Annual appraisal – this is to be enhanced

Multi source feedback (360 degree appraisal) x 2 in 5 years

Statement from PCT MD that there are no unresolved performance issues

What is the evidence portfolio?

See www.appraisals.nhs.uk for the current appraisal portfolio; this will be developed and enhanced

Evidence will be the most important development, moving appraisal away from rhetoric and anecdote. It will comprise:

Professional roles and basic detailsStatement of exceptional circumstancesEvidence of annual appraisalPDP each yearMSF x 2Patient feedback

Portfolio cont’d

Causes of concern and/or formal complaints

Significant event audit

Clinical audit: 2 completed cycles in each 5 yearly cycle

Probity and health

Extended practice eg. GPwSI, VTS, teaching, research, medical management

The non standard portfolio

The non-standard portfolio

This could apply to locums or those working less that FT

Doctors with no clinical practise for 5 years will not be recertified

The doctor’s working environment provides the revalidation context

Minimum standards:Annual appraisal and PDP in at least 3 out of 5 years50 learning credits in each of the 3 to 5 yearsDocumentation of at least 200 clinical half day sessions (1 day weekly)Registrars: The MRCGP will satisfy revalidation requirements

Learning credits

Each doctor will require a minimum of 50 annual learning credits, 250 for the 5 yearly revalidation cycle

1 credit = 1 hour of learning – lecture, reading, etc

If learning leads to changes for patients, the doctor or the practice, the GP can claim 2 credits/hr.

These credits will be challenged by the appraiser or Responsible Officer and will need defending. The challenge could be due to too many credits claimed or too little

The Responsible Officer

A new role. Likely to be the MD

Has responsibility to the GMC

The annual appraiser informs the RO that a particular doctor’s annual appraisal is satisfactory. Every 5 years, this would be satisfactory for revalidation provided the other components are satisfactory too

The RO will have access to the appraisees/appraisers confidential appraisal documents

Key personal responsibilities

The appraisee must demonstrate to the appraiser that he/she is fit to practise

The appraiser has the responsibility to approve the appraisal, or not

Appraisees who are in difficulty must communicate with their appraiser or RO and seek help and assistance

The GMC recertifies the doctor for the next 5 yearly cycle

Finally, there are nationwide pilots at present. These will report to the National Revalidation Board in order to determine best practise