Life inside a hub: Top medicolegal challenges

Medicolegal Adviser Dr Helen Hartley provides advice on the top medicolegal challenges posed by new care models.

To safely deliver new care models it is essential that practices adapt their processes and structures. Processes that successfully deliver safe and effective care in a small, single partner practice are not likely to cater to all the risks faced by a practice in a new care model, or working at scale in a group or federation.
For example, many new care models extend the roles for other health professionals, including paramedics, physiotherapists, mental health workers, physician associates and pharmacists. Any practice bringing in these new roles will need to have clearly defined scopes of practice and supervision arrangements, and that is just the start. Below are some of the top medicolegal risks that we have identified in new care models, along with advice on how to counteract these risks and continue to deliver safe, coordinated care.

Access to patient records for continuity of care and triage

Where practices join together, either tightly in a formal federation, or loosely in a hub network, it is likely that patients will receive some care away from their usual practice. Safe and effective care from a different practice is more achievable when healthcare staff can access records held by the patient’s base practice, so that they are aware of the patient’s past medical history, medications and any recent attendances. Access to patient records is particularly important when a patient attends another practice with an acute medical problem.

Effective collaboration and communication between practices will enable GPs to resume care seamlessly, minimising the delays sometimes seen when patients attend A&E departments or Urgent Care Centres. Explaining to patients the motives and expected benefits of sharing medical records with partnership practices is likely to help when seeking to obtain patients consent to do so. However, you should remember that GMC guidance (Confidentiality, 2009, paragraphs 25-27) advocates respecting the wishes of any patient objecting to the sharing of particular personal information within the healthcare team, unless disclosure is considered essential for providing safe care.

Collaboration has allowed some vanguard practices to expand service capacity, including during extended and unscheduled hours. As well as shared records access, effective triage is vital: technology can assist here to prioritise patients by the urgency or complexity of their clinical needs.

Alongside telephone triage, video or email consultations have enabled some practices to target specialised services at some patients who might otherwise find it difficult to access care, for example, travellers and patients with substance abuse. When using new methods of communication with patients it is important to consider matters of consent, confidentiality, maintaining professional boundaries and retention of all patient communications in the medical records.1,2

Induction, training and supervision

Increased collaboration between practices requires consideration of the benefit of harmonising policies and protocols, including the induction of new staff and the training needs of existing staff.

Staff, especially those working across practices, require clarity regarding their roles, reporting arrangements and resources, including access to supervision. This is especially important for new healthcare roles in primary care, in order to determine professional accountability. It also assists patients to understand who is treating them and what they can offer. Collaborating practices can benefit from economies of scale in providing for the training and CPD needs of primary care teams, including ensuring appropriate supervision of those staff subject to regulatory requirements for workplace reporting and supervision. 

Handling practice clinical administration

Sharing best practice regarding processes and policies allows clinical protocol harmonisation – a good example of which is handling investigation results. Reducing the risk of failing to act on abnormal results, for example in relation to INR monitoring, PSA testing and renal function testing, is likely to decrease adverse events and have a beneficial impact on complaints and litigation.

Similar benefits are possible from sharing best practice in relation to handling medication reviews and repeat prescription requests. Doctors signing prescriptions should satisfy themselves that the drugs will appropriately meet a patient’s clinical needs (GMC Prescribing guidance, 2013, paragraph 61). 

Learning from complaints and significant events

As well as helping with the implementation of approved national guidance and the undertaking of an audit through shared clinical governance support staff, hub-working provides for effective and objective complaints handling. This is because a practice is able to obtain independent peer reviews of its complaints and significant events from a hub partner. Further, any lessons learned can be shared across the network, allowing central modification of protocols or processes to minimise the recurrence of similar complaints or adverse events. 

Indemnity

Good Medical Practice requires doctors to have adequate indemnity cover (GMC, 2013, paragraph 63). Occurrence-based indemnity provides cover for claims arising from medical malpractice which occurred during a period of medical defence organisation membership. A doctor’s individual professional indemnity is personal to them, although a GP partner employing staff may be able to extend the protection to vicarious liability for employee negligence. GPs should always check the provisions of their indemnity to make sure it is suitable for their needs. Federations may require corporate indemnity against clinical negligence, and while such indemnity should protect employed staff, any employed doctors should check the adequacy of the indemnity for their own needs. Corporate indemnity insurance is often provided on a claims-made basis, meaning that it applies to claims reported, and care given, during a period of corporate membership. As corporate claims insurance does not usually protect employees for ‘non-claims’ events such as complaints, inquests, disciplinary, regulatory or criminal investigations, or the provision of medicolegal advice, we recommend that doctors consider maintaining personal membership of a medical defence organisation for ‘non-claims’ protection.

References

1. Communicating with patients by text message (MPS factsheet)
2. Making audio and visual recordings of patients (MPS factsheet)