In response to the work that healthcare workers are undertaking during the COVID-19 crisis, all retired or deferred members of Medical Protection will have their indemnity membership with us automatically reinstated completely free of charge. This is for state-indemnified work only.

This means that whilst the state will indemnify your for any claims that could arise as a result of you undertaking this work, Medical Protection can offer assistance with other matters such as medicolegal advice and regulatory representation, support with complaints, disciplinary proceedings, inquests and criminal investigations arising from clinical practice.

Before starting it is vital you seek written confirmation from the Hospital as to your duties, and whether they expect you to hold GMC registration and a License to Practice or international equivalent, and to confirm that the Hospital will provide you with an indemnity in the event of a claim of clinical negligence is made. 

Medical Protection would also expect you to work within the limits of your competence.

The World Health Organization’s (WHO) advice in relation to infection prevention and control measures for healthcare workers caring for a patient with suspected or confirmed Covid-19 states that contact and droplet precautions are recommended for all healthcare workers caring for a patient with suspected/confirmedCovid-19. The WHO advise that provision of appropriate personal protective equipment supplies should be a national and institutional priority.

Members are always advised to follow the guidance in your country in relation to what PPE must be worn and when.

There may be occasions when you believe that it is justifiable not to see a patient without adequate Personal Protective Equipment. Ultimately there is a limit to the risk that you would be expected to put yourself at in order to provide treatment to a patient. You should however consider the GMC’s guidance on this matter a link to which is provided below.

https://www.gmc-uk.org/ethical-guidance/ethical-hub/covid-19-questions-and-answers

In the section of the GMC’s Covid 19 guidance entitled “Working Safely” the following is stated:

“We do not expect doctors to leave patients without treatment, but we also don’t expect them to provide care without regard to the risks to themselves or others. This pandemic is an unprecedented challenge in which clinicians are understandably balancing the imperative to provide care with their own fears. 

We understand that this may lead to doctors having to make very difficult decisions where they have to use their professional judgement.

Doctors will need to consider:

· whether treatment can be delayed, or provided by another team;

· what course of action is likely to result in the least harm in the circumstances;

· whether alternative actions or additional steps can be taken to minimise the risk of transmission;

· whether any doctors or other healthcare professionals are at a higher risk from infection than other colleagues.

You should try to work with colleagues to find the best way forward in the circumstances. Our expectation is that doctors will do their best in the circumstances they face, considering the welfare of the patient and the risk to their own or others’ health to make these difficult decisions.”

The same FAQs go on to say:

“While a lower standard of PPE may increase risk to some degree, doctors would need to consider how to provide care to patients, including whether the available equipment allows treatment to continue. 

If having tried and exhausted alternative means of treating a patient you believe that this is not possible without unreasonable risk to you and to other healthcare professionals, you should escalate your concerns, record your decision and how you tried to address safety concerns.”

The British Medical Association are also addressing this issue in detail, and their details guidance can be found in the following link:

https://www.bma.org.uk/advice-and-support/covid-19/your-health-and-wellbeing/covid-19-refusing-to-treat-where-ppe-is-inadequate

In this guidance entitled “COVID-19: refusing to treat where PPE is inadequate” the BMA, in addition to providing advice on raising concerns, take the following view:

“…there are limits to the risks you can be expected to expose yourself to. You are under no obligation to provide high-risk services without appropriate safety and protection. You can refuse to treat patients if your PPE is inadequate, you are at high risk of infection and there is no other way of delivering the care.”

In is clear that employers should be providing adequate Personal Protective Equipment to allow doctors and other health professionals to do their jobs safely. If you are concerned that such equipment is not being supplied, or is in short supply and likely to run out, you should raise concerns in line with the local process for raising concerns within your organisation in the first instance.

If you are asked to see a patient without the appropriate Personal Protective Equipment, each situation will need to be considered on a case by case basis. You are urged to consider the GMC’s guidance on this matter in making any decision. You should of course be prepared to justify any decision you make in the event that this decision becomes subject of a complaint or investigation at a later time. You should also ensure that any reasoning for any decisions that you make are carefully documented.

Medical Protection members who do find themselves subject to regulatory or disciplinary proceedings as a consequence of not seeing a patient because there was a lack of appropriate Personal Protective Equipment can contact Medical Protection to seek advice, support and representation.

Medical Protection has called upon the GMC and employers to provide reassurance that doctors with not face action as a consequence of inadequate provision of PPE. Further details can be found in the following press release: https://www.medicalprotection.org/uk/articles/doctors-should-not-face-investigation-if-they-decide-they-cannot-see-a-patient-due-to-poor-ppe-provision

If you know or suspect you are infected, you should follow the current advice from your regulator and Public Health authorities, including self-isolating.

Where possible it is important to make alternate arrangements for patients so their care is not compromised, this may include delegating to a colleague or signposting them to other resources.

Should a patient make a complaint to a regulator, that you were unable to see them, it is important to be able to demonstrate that you acted in accordance with advice from your regulatory body and Public Health authorities.

United Kingdom
The GMC guidance ‘Good Medical Practice’ at paragraph 28  states that:

“If you know or suspect you have a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients.”

Ireland
The Medical Council in Ireland provides equivalent guidance in its document “Guide to professional conduct and ethics for registered medical practitioners” which states, at paragraph 58.2  

“If you have an illness which could be a risk to patients or which could seriously impair your judgement, you must consult an appropriately-qualified professional and follow their advice.  This professional will have a dual role: to help and counsel you, and to make sure you do not pose a risk to patients and others. If such a risk exists, you must inform the Medical Council as soon as possible.”

The level of resourcing (including the number of available ventilators and who is eligible for them) should be a matter for the Trust/Health Board. When resources are limited, dialogue between clinical staff and the body responsible for allocating limited resources needs to take place. In a hugely challenging environment such as this when resources may well be unavailable, doctors and employers will face major ethical challenges on ITU, as elsewhere.

The GMC’s duties of a doctor require that you make the care of your patient your first concern. Paragraph 25 of ‘Good Medical Practice’ states, "you must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised."

In response to the COVID-19 Pandemic the GMC has issued guidance which can be read here:
https://www.gmc-uk.org/news/news-archive/supporting-doctors-in-the-event-of-a-covid19-epidemic-in-the-uk

It states:

"We need to stick to the basic principles of being a good doctor. All doctors are expected to follow GMC guidance and use their judgement in applying the principles to the situations they face, but these rightly take account of the realities of a very abnormal emergency situation. We want doctors, in partnership with patients, always to use their professional judgement to assess risk and to make sure people receive safe care, informed by the values and principles set out in their professional standards. A rational approach to varying practice in an emergency is part of that professional response."

For those doctors working within an NHS setting, should a claim in negligence arise from the lack of suitable resources, it would be a matter for the Trust or Health Board.

In the event of a complaint to the GMC the doctor would be expected to be able to demonstrate that they complied with their professional obligations as set out in the above guidance.

No, please leave the direct debit instruction in place, we will not collect payments on this during the period of deferred membership.

The recently introduced Coronavirus Act 2020 removes some of the limitations placed on doctors completing a MCCD, in acknowledgment of the current restrictions on clinical practice.

NHS England and NHS Improvement have produced the following helpful guidance on this matter:

Coronavirus Act – excess death provisions: information and guidance for medical practitioners

Further, more detailed guidance can be found here:

Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales

The Act now allows a doctor to complete an MCCD for a patient who has not been seen by a clinician within the 28 days prior to death, providing they are able to state the cause of death to the best of their knowledge and belief. This is likely to require a review of the patient’s medical record to gain an understanding of their past medical history and any recent care they have received.

Deaths should still be referred to the Coroner if a doctor is unable to state a cause of death or in situations where the death was violent or unexpected, as was the case prior to the Coronavirus Act.

The changes above are of a temporary nature during the Coronavirus emergency.