Situations where a doctor is both an employer and the treating clinician of a patient are problematic and should be avoided. Sarah Pickering, advisory case manager at Medical Protection, looks at a recent query from the advice line

In a call to Medical Protection, a GP partner reported that she had recently joined a practice where the majority of its reception and healthcare assistant (HCA) staff were also registered as patients. This had been the case for years; the staff enjoyed unique access to the appointment system and booked their own appointments when needed.

The GP partner felt uncomfortable with this current arrangement and could foresee situations in which conflicts of interest could arise.  The practice was located in an urban area with a number of other surgeries around for staff to register at. However, the partners felt it was unfair to ask the staff to deregister, especially as many of them had been patients for years.

Advice

The GMC states in paragraph 16(g) of Good Medical Practice: “In providing clinical care you must wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship.”

The GMC also states in paragraph 17 of Good practice in prescribing and managing medicines and devices: “Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close personal relationship.”

Both pieces of guidance could be interpreted widely as including work colleagues. It is therefore advisable to adopt a practice policy whereby staff are discouraged from registering as patients, especially if there are other practices available nearby. In this case, the practice was not a rural or isolated practice and there were numerous other local options.

The GP partner was also advised that revising the practice policy would help avoid difficult situations arising in future. With a significant number of staff already registered as patients, the GP partner was also advised to consider the following:

• It may be difficult for GPs to maintain clinical objectivity when treating a colleague, which may in turn subvert the normal doctor-patient relationship.
• There may be situations that could put the doctor in a very difficult position. If, for example, a clinical staff member sought advice regarding alcohol abuse, a partner would be in a very difficult position of having to care for the patient while also taking appropriate steps as an employer to ensure patient safety. Another example may be where a staff member seeks a fit note to take time off work due to work-related stress, which again would put a partner in a difficult position as the employer. Staff members should be treated no differently from other patients but, in some situations, there could be conflicts of interest and difficult medicolegal issues may arise.
• Patients who are also staff may find it more difficult to talk openly about their health to a GP who they work with. This may lead to the patient/staff member withholding information that is vital to a diagnosis or management of a condition. They may also feel unable to refuse treatment or seek alternative approaches. Questioning a recommendation or seeking a second opinion may be seen, by either party, as demonstrating a lack of trust.
• Practices must have a policy in place to ensure that patient confidentiality is maintained at all times and it is advisable that all staff sign a confidentiality agreement and undergo training on confidentiality and data protection. When staff are registered as patients it is inevitable that certain members of the team will have access to their record and may need to access it. Practice policy should be that access to patient records should only occur if necessary and required, such as when consulting with the patient, booking an appointment or scanning their records.
• A practice could be criticised for having a policy that favours staff members as patients over other patients. Any staff members who are registered as patients should not be given preferential treatment in any way, either clinically or administratively. Having first access to appointments could be perceived as treating staff members as patients more favourably and could attract criticism.

The GP partner was also advised that if asking a staff member to move to a different practice would be detrimental to their health; would pose a great practical difficulty; or if the patient had a strong preference to remain on the list; then the wishes and best interests of the patient should be taken into account. However, they should be balanced against the risks outlined above. The GP partner was advised to discuss the risks and considerations outlined above with staff who are registered at the practice in order to encourage staff to register elsewhere of their own accord.