There are 6 sub-sections:
25.4 Clinical Care
25.5 Clinical Governance
25.6 Clinical Supervision
This involves a variety of things and the sites given in references would be most helpful for staff and patients to go through.
Official gateway sites include information about NHS organisations, local NHS services, what the NHS does, how it works, and how to use it. You can search for details of doctors, dentists, opticians, pharmacies, walk-in centres, hospitals, etc. You can look at performance indicators to see how your local services are doing, waiting times, etc.
NHS 111 England – Call 111 (24 hours) if you urgently need medical help or advice but it’s not a life-threatening situation.
25.1 Rights and Responsibilities
Patients should be treated with respect and as a customer in GP’s care. Being a customer means a patient has responsibilities too.
- Ensure patients have 24-hour access to medical advice
- Aim for patients to have access to a suitably qualified medical professional within 48 hours of one’s initial contact during surgery hours, or in an urgent case, the same day
- Work in partnership with patients to achieve the best medical care possible. Involve the patient and listen to his/her opinions and views in all aspects of medical care.
The patients are requested that they:
- Let the practice know if they intend to cancel an appointment or are running late
- Treat staff with courtesy and respect. Reception staff may have to ask some personal questions to assist GPs in providing the patients with the best service.
- Inform the practice staff of any alterations in their circumstances, such as change of surname, address, telephone number, marital status etc. Please ensure that the Practice have their correct telephone number, even if it’s ex-directory.
The prevention of disease, illness and injury is a primary concern. The medical staff will advise and inform the patients of the steps to take to promote good health and a healthy lifestyle. Patients are responsible for their own health and that of any dependents. It is important that patients adhere to information and advice given to by health professionals, and co-operate with the practice in endeavouring to keep the patients healthy.
Zero Tolerance Policy
The practice considers aggressive behaviour to be any personal, abusive and/or aggressive comments, cursing and/or swearing, physical contact and/or aggressive gestures.
The practice will request the removal of any patient from the practice list who is aggressive or abusive towards a doctor, member of staff, other patient, or who damages property. All instances of actual physical abuse will be reported to the police as an assault.
Confidentiality / Data Protection
Doctors and staff use a computer to hold patient information to enable them to provide good continuity of care. Patient’s data are always kept securely. Some of it may be used by other authorised agencies e.g. district nurses and hospital consultants.
The surgery is registered under the Data Protection Act.
Comments and Suggestions
GP surgeries should always happy to accept comments and suggestions from their patients. These should be discussed regularly in monthly Practice Meetings.
Data Protection Act
The Data Protection Act 1998 came into force in March 2000. Its purpose is to protect the right of the individual to privacy with respect to the processing of personal data. The Act laid down eight data protection principles:
- Data must be processed fairly and lawfully.
- Personal data shall be obtained only for one or more specific and lawful purposes.
- Personal data shall be adequate, relevant and not excessive in relation to the purpose(s) for which they are processed.
- Personal data shall be accurate and where necessary kept up to date.
- Personal data processed for any purpose(s) shall not be kept for longer than is necessary for that purpose.
- Personal data shall be processed in accordance with the rights of data subjects under the 1998 Data Protection Act.
- Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or destruction of, or damage to, personal data.
- Personal data shall not be transferred to a country outside the EEA, unless that country or territory ensures an adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data.
25.3 Whistle blowing
If staff brings information about a wrongdoing to the attention of their employers or a relevant organisation, they are protected in certain circumstances under the Public Interest Disclosure Act 1998. This is commonly referred to as ‘blowing the whistle’. The law that protects whistle-blowers is for the public interest. So people are encouraged to speak out if they find malpractice in an organisation. Blowing the whistle is more formally known as ‘making a disclosure in the public interest’.
Qualifying disclosures are disclosures of information where the worker reasonably believes one or more of the following matters is either happening, has taken place, or is likely to happen in the future:
- A criminal offence
- The breach of a legal obligation
- A miscarriage of justice
- A danger to the health and safety of any individual
- Damage to the environment
- Deliberate attempt to conceal any of the above.
If a staff is going to make a disclosure it should be made to the PMgr or GP Partner, so that employment rights are protected.
Staff who ‘blow the whistle’ on wrongdoing in the workplace can complain to an employment tribunal, if they are dismissed or victimised for doing so. An employee’s dismissal (or selection for redundancy) is automatically considered ‘unfair’ if it is wholly or mainly for making a protected disclosure.
25.3.1 How to ‘blow the whistle’
The way a worker can ‘blow the whistle’ on wrongdoing depends on whether they feel they can tell their employer.
The worker should check their employment contract or ask human resources/personnel if their company has a whistleblowing procedure.
If they feel they can, they should contact their employer about the issue they want to report
If they can’t tell their employer, they should contact a ‘prescribed person or body’.
A worker can only tell the prescribed person or body, if they think their employer:
- Will cover it up
- Would treat them unfairly if they complained
- Hasn’t sorted it out and they’ve already told them.
25.3.2 Dismissals and whistleblowing
A staff can’t be dismissed because of whistleblowing. If they are, they can claim unfair dismissal – they’ll be protected by law as long as certain criteria are met.
Types of whistleblowing eligible for protection. These are called ‘qualifying disclosures’. They include when someone reports:
- That someone’s health and safety is in danger
- Damage to the environment
- A criminal offence
- That the company isn’t obeying the law (like not having the right insurance)
- That someone’s covering up wrongdoing
25.3.3 who is protected
The following people are protected:
- Agency workers
- People that are training with an employer, but not employed
- Self-employed workers, if supervised or working off-site.
25.3.4 Who’s not protected
Workers aren’t protected from dismissal if:
- They break the law when they report something (e.g. they signed the Official Secrets Act)
- They found out about the wrongdoing when someone wanted legal advice (‘legal professional privilege’) – e.g. if they’re a solicitor.
If a worker is dismissed for whistleblowing, they can go to an Employment Tribunal.
If the tribunal decides the employee has been unfairly dismissed, it will order that they are:
- Reinstated (get their job back)
- Paid compensation.
25.3.6 Whistleblowing abroad
Workers are protected from unfair treatment even they blow the whistle on something that happened abroad. This includes when a different country’s law has been or will be broken.
25.3.7 Whistleblowing Policies
Practical Guidance on Whistleblowing in the NHS from Public Concern at Work.
Week in and week out doctors blow the whistle across the NHS. Few of these doctors will think of themselves as whistle-blowers, insisting that they are just doing their job.
This is understandable as, for many, the perceived characteristic of whistleblowing remains that the message is not heard, the messenger gets crucified and it all ends in tears. Essentially what this means is that only when the message is unwelcome is it considered to be whistleblowing.
However, the culture is changing and people up and down the NHS are much more aware today that they may have to account for their actions. This helps inject an element of self-discipline and circumspection when people are presented with difficult choices. Recent initiatives mean that many, if not most, NHS Trusts are committed to promoting responsible whistleblowing as an essential aspect of good clinical governance. Whistleblowing in today’s NHS need not end in tears.
Before you blow the whistle, it’s always a good idea to be very clear about the limits of your own responsibility. First, a whistle-blower is a witness, not a complainant. Secondly, a likely consequence of not blowing the whistle is the Chief Executive or Chair saying “Why didn’t anybody tell us?” or “If only we had known …” The treatment, then, should be to let the facts speak for themselves and allow those responsible to take an informed decision.
The Public Interest Disclosure Act 1998 (PIDA) was introduced to protect employees who are worried about wrongdoing in their place of work and want to ‘blow the whistle’.
The act applies to all NHS employees and includes all self-employed NHS professionals (i.e. doctors, dentists, opticians, optometrists, and pharmacists). For the purposes of the Act, the employer of self-employed NHS professionals is deemed to be the relevant primary care trust or health authority.
An employee who is victimised or penalised for making a protected disclosure can bring an action for compensation against the employer at an Employment Tribunal. Some 1,200 employees have taken their employer to Employment Tribunal since the Act came into force and it is estimated that employers in compensation every year pay out some £10 million. The largest single award to date was £805,000.
My sincere advice to all, particularly to all non-clinical staff:
- Read the references given on whistleblowing carefully
- All non-clinical staff does not have any cover from powerful external organisations as GPs and Nurses have. CAB is helpful but you are on your own – in terms of lost time, aggro, stress, loss of job and earnings.
- There may be many government legislations to protect staff etc. but in final count you will be in a limbo
- For an individual the best protection is to keep quiet (unless a murder takes place!) and get on with one’s work oblivious of the surroundings.
- Observe and learn – should be the two key objectives and soak up all the knowledge that Practice experience would give you.
On contentious issues, there are no friends and do not confide your worries to any colleague or mates. In the end you would be the loser and get bitter.
Do let these perception issues affect your personality.
25.4 Clinical Care
Good clinical care:
Most surgeries have practitioners who have been in the NHS for several years including General Practice experience. The nurses may also be qualified and trained and have several years experience. Consequently, the general patient care is of a high quality. They all should go for regular training courses or seminars organised by HTPCT.
The areas to improve would be in data input due to some practitioners not being fast enough in the use of computers. Consequently, some surgeries may still have a dual system of computer and records.
- Maintaining good clinical practice:
More informal and formal discussions by the practitioners and nurses would improve further the clinical practice. The practitioners need to be aware of new guidelines, which come very frequently and with exhaustive protocols. Continual upgrading of skills and knowledge base is crucial to maintain good clinical care.
- Teaching and Training:
There should be an induction period for GPs, nurses and admin. staff and procedures are in file. All staff should go through in-house and PCT courses to improve their skills. Appraisals should be done once a year for all staff in the practice. External personnel do GP assessment. Some practices may not be a teaching practice and GP Registrar’s are not employed.
- Relationship with patients
Surgery should have very good relationship with the patients and should have very few complaints.
Patient surveys should be conducted each year and improvements made from the comments made.
Dealing with problems arising should be in most professional manner. This includes dealing with irate patients. The practice manager should respond in a cool and calm manner even under intense provocation.
- Working with colleagues
The practice should have a good team concept and the staff motivated to get on well with each other. The staff, mostly young ones, who leave should be very few and even in those cases, due to college or home pressures, they should be advised to come back to re-join. The same applies for the nurses and the GPs.
25.5 Clinical Governance
Practice Managers should be very aware of clinical governance procedures as these become crucial when a practice has to endure remedial issues and adverse actions usually taken by PCTs. Most managers and the GPs have a ‘blind spot’ for these procedures.
It is a framework through which NHS organisations are accountable for continually
- Improving the quality of their services
- Safeguarding high standards of care.
Three key attributes:
- High standards of care,
- Transparent responsibility and accountability for those standards,
- A constant dynamic of improvement.
Clinical governance is composed of at least the following elements:
- Education and Training – continual professional development of clinicians
- Clinical audit
- Clinical effectiveness
- Research and development
- Risk management – for patients, for practitioners and for the practice
- Information Management – keeping all records accurately.
Clinical governance aims to integrate the various systems for quality improvement and professional development and to ensure that everyone in the practice team becomes involved. Indeed, an underlying challenge for clinical governance in primary care is to move away from professional development based on uni-disciplinary education towards multidisciplinary, team based learning. However, there are also potential problems with multidisciplinary learning in general practice. These include issues of hierarchy, gender, and varied educational achievements in team members, all of which may act as barriers to effective learning.
Problems with underperformance might become evident through the review of care for continuing professional development, performance monitoring, annual appraisal, patient surveys, complaints, or revalidation. However, once underperformance is identified, the individual clinician, the practice, and the leader for clinical governance should act to ensure that care is improved.
Actions should include an assessment of the doctors or nurses in the context in which they work. Some underperformance is due to local deprivation and health inequities, some is due to poor systems of care, and some may be due to under-resourcing. Where it is due to an individual, the cause may be a health problem or problems with competency or behaviour.
Whichever it is, there needs to be an accurate and agreed “diagnosis” and a “management plan.” The latter must, in time, include the capacity to remove a doctor or nurse from active practice, if appropriate, while they are retrained. A locum will be needed to cover patients while a failing clinician is rescued.
Effective clinical practice requires access to and use of evidence-based guidance on cost effective care. To implement national service frameworks and local health improvement priorities, staff will need to understand what these priorities are and monitor progress towards agreed standards.
Many primary care practitioners even now remain unsure about the meaning of clinical governance and about the changes needed within a practice to implement it.
All should look in the website of RCGP, BMA, Pulse, GP commissioning, NICE etc. to become aware of the details of the clinical governance and what it means for the practice.
Clinical Governance is the way surgery ensures it has in place the right people and right systems so that it continues to provide patients / customers with the highest standards of care. Clinical Governance is implemented through a framework, which promotes consumer participation, clinical effectiveness, as an effective workforce and risk management.
- Infection Prevention and Control is an important Unit that is responsible for monitoring infection prevention and risks to patients and staff, to ensure a safe hospital environment. Surgery should implement measures to reduce infections and the impact of those infections on patients. Surgery staff is encouraged to develop guidelines and policies that guide clinical practice, educate, support and monitor staff in infection control practices including hand hygiene and staff immunisation.
- The Mortality, Morbidity and Major Review to be carried out on patient safety issues. The Committee reviews sentinel events, serious adverse events and deaths with the assistance of independent audit undertaken by an external medical expert.
- Patient Safety is everyone’s responsibility and fully investigates types of events to improve practice.
- Surgery is responsible for responding to complaints and concerns. These should be viewed as providing an opportunity to better understand how best to improve its services.
Some examples are given to illustrate the nature of quality improvement for clinical governance:
a. Repeat prescription:
A patient wanted more than 3 repeat prescriptions.
The issue was stopped and patient was called to come for an appointment. Medication review took place and then only prescription given.
GPs must see all patients if repeat of more than 3 were requested – exceptions are for mental health patients.
b. New Registration:
A patient needed urgent hospital referral due to severe pain. Despite his temporary registration, action was taken by GP to send the patient to hospital due to urgent nature of illness. Normal procedures for accepting to register the list or sending to walking centre ignored due to special circumstances.
- Critical Event Recording:
- a.Patient A – Referral to hospital when HB values less than 5
- Arrange for blood transfusion referral, if required.
- Immediate appointment should mean same day or next morning consultation and not clinic appointment.
- Patient B
When a patient fasting glucose is very high, then arrange for medication immediately. Refer to hospital if necessary for monitoring.
- Clopidogrel audit conducted audit for 13 patients following Prescription advisers visit. Either stopped or changed medication to aspirin, after reviewing each patient.
25.6 Clinical Supervision
Clinical supervision provides an opportunity for staff to:
- Reflect on and review their practice.
- Discuss individual cases in depth.
- Change or modify their practice and identify training and continuing development needs.
Clinical supervision is often primarily aimed at registered professionals (for example, nurses, doctors, social workers and allied health professionals).
- Has highlighted the need to enforce more vigourously the clinical supervision procedures to
ensure similar slip up does not occur.
- The clinical supervision would involve all staff- clinical and admin.
- The Doctors, new and existing, would be supervised quarterly by Partners on various cases
of patients handled by the doctor concerned to ensure the procedures and protocols are
- Nurses and admin. The Partners and Practice Manager would supervise nurses and staff
respectively, again at quarterly intervals.
- Lessons learnt would be discussed in the monthly meetings to highlight areas of concern and where
remedial actions were taken to correct it.
- CDM (Clinical Decision Making) procedures and particular attention to mental health and cancer
patients would be focused to ensure conformity to guidelines.
- Prescribing and repeat prescriptions, not collecting prescriptions etc. would be areas where
receptionist can alert practice manager and through her the partners.