Featuring: Making SEA work for you / Dealing with aggressive patients / Texting pitfalls / Ethics: It’s the small things

DIY health An award-winning project providing parents with the knowledge and confidence to manage minor ailments in under-fives Welcome Editor Dollman Greg Dr chair in Scotland. chair inScotland. obstetrician andgynaecologist, andthefirstprofessorial along withavignetteofDrMargaret Fairlie –pioneering filmthrillerDarkWaterBody andthecorporatecrime , imaging, reviewsofBillBryson’s brilliantnewbookThe patient withabdominalpain. allegations ofdelayed diagnosisofappendicitisina managers, andourcasestudyonpage 12 so common)advice requestsfrom GPsandpractice sensitively withpatients. can reflectethicalchoiceswhenitcomes to dealing perspective (page 13 named PrimaryCareTeam oftheYear. impressed thejudgesat2019BMJAwards thatitwas ‘DIYHealth’care amongparentsofchildrenaged0-5. so practices inTower HamletsLondonby promoting self- about aprogramme helpingto easepressureonGP implications. Inourprofile featureonpage 8 of textingto contactpatientsandthedataprotection our regular riskcolumnonpage 7 patients whileensuringpracticestaffare kept safe,and exercises. tips onmakingSEAsmorethanjustsimplebox-ticking than analysis.Onpage 10 many oftheSEAsweseeatMDDUSaremoredescription comments andsuggestions aremostwelcome. find thisinaugural issuebothinterestinganduseful. All opinions or policies ofMDDUS. – PrimaryCare arethoseof theauthorsaloneand donotnecessarilyreflecthe t The opinions,beliefsand viewpointsexpressedbythevariousauthors inInsight MDDUS arediscretionary assetoutinthe Articles of Association. The MDDUSisnotan insurance company. All thebenefitsofmembership of com Marketing:[email protected] Website: www.mddus.com Email: General:[email protected] Membershipservices:membership@mddus. Blythswood Street,GlasgowG24EA. Tel: 03330434444Fax: 0141228 1208 Union ofScotland,registeredinScotlandNo5093 atMackintoshHouse,120 Insight –PrimaryCareispublishedquarterlyby The Medical andDentalDefence www.connectmedia.cc 0131 5610020 Connect Communications DESIGN Joanne Curran Jim Killgore MANAGING EDITOR Greg Dollman EDITOR COVER PHOTOGRAPH: DOMINICK TYLER ASSOCIATE Addenda onpage 14 Our Calllogonpage 4 Professor Bowman Deborah offersapersonal On page 6 Significant event analysisisnoteasy to getrightand EDITOR welookathow to dealwithaggressive ) onhow even “small things” includes some curious cardiac includessomecuriouscardiac features common (and not featurescommon(andnot of this issue, Liz Price offers ofthisissue,LizPriceoffers w: www.mddus.com e: [email protected] t: Glasgow G24EA 120 BlythswoodStreet Mackintosh House MDDUS Legal: JoannaJervis Medical: DrRichardBrittain E DITORIAL DEPARTMENTS concerns the use concernstheuse editor andhopeyou to take ontherole of page 3 dental members(see for allourmedicaland of contentweproduce to broaden thescope launching atMDDUS magazines weare three newquarterly Primary Care –oneof first issueofInsight WELCOME to the 0333 0434444 concerns concerns ). I am excited ). Iamexcited Dr GregDollman , we hear , wehear Editor section ofmddus.com page go to theAdvice andSupport Member wellbeingandmentalhealth avoiding burnout.To accessthe members onkeeping welland some guidance andresourcesfor demand. MDDUShasproduced are underpressurewithincreasing very highriskofburnout–andallstaff that nearlynineoutof10GPpartnersareathighor 2019 BritishMedicalAssociation(BMA)reportfound but how doyou lookafteryour own wellbeing?A PATIENT caremay come firstformedicalprofessionals What about you? be given theresourcesforpatientfollow-up. reasons fornon-attendancemay becomplexandpracticesmust but somemay issuewarningletters.TheRCGPsaidthatthe tackle theproblem, includingtextreminders,emailsorletters, persistent non-attenders.Mostsurgeries usearangeoftacticsto professionals. to seedoctors, withtherestfornursesorotherhealthcare of 42,822perday. Around halfoftheappointments were patients inEngland“did notattend” (DNA) –anaverage published by The Times. year, accordingto analysisoflatestfigures from NHSDigital every month inEngland,costingtheNHS£200milliona MORE thanonemillionpeoplefail to attendGPappointments monthly missed Million WELLBEING GP APPOINTMENTS The NHS has no formal national policy for dealing with The NHShasnoformalnationalpolicyfordealingwith In theperiodfrom Juneto November 2019,7.8million

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WORKFORCE RCGP sets roadmap

GENERAL practice is “running on empty” with ever increasing patient demand and falling GP numbers, says the Royal College of General Practitioners in a statement setting out a new Workforce Roadmap. The plan details what must be done to ensure general practice has enough GPs and practice staff to deliver safe, high- quality patient care if the Government is to achieve its manifesto pledge of 6,000 INDEMNITY more GPs and 50 million more patient consultations. The RCGP points out that from September to November 2019, GPs in Extended cover England undertook 41.9 million patient consultations, which is 450,000 more than for practice staff the same period in the previous year - this MDDUS can provide extended indemnity, legal support and advice/assistance despite a drop in the to non-GP practice staff in England and Wales for activities and risks not number of full-time- covered under new state-backed schemes. Under our Primary Care Team equivalent GPs. m Professional Advice Protection plan all non-GP members on the practice team RCGP chair GP42 CONSULTATIONS can enjoy access to expert advice and support with complaints arising from Professor Martin clinical practice indemnified by state-backed schemes in England and Wales Marshall said: “Unfortunately, general (CNSGP and GMPI, respectively). In England this includes NHS primary medical practice has been running on empty for services delivered on behalf of the Primary Care Network. too long… The impact of these measures The plan is provided free to practices where GP partners are all MDDUS will be to significantly improve the access members. In practices where all GP partners are not in MDDUS membership to our service and the quality of the care we there will be an annual charge of £50 per regulated team member. Non- can give to our patients.” regulated staff (e.g. HCAs) will be covered free of charge. MDDUS also offers an essential extension to the above plan for individual regulated non-GP staff. Find out more at tinyurl.com/y4a2cogl.

An Insight for primary care LAST year we launched the first our current range of magazines edition of a new digital Insight, (including GPST and Practice Manager) generated using the premium with three branded quarterly digital digital magazine platform, Foleon. and print magazine titles. The switch to digital was part of a Insight Primary Care is the first of larger initiative to reconsider our these magazines with a secondary publication programme and how care publication launched in April best to communicate with members and a dental in May. All the Insight going forward in 2020. titles will be generated using Foleon We have now decided to broaden and sent out via an email link, but the scope of the content we produce those existing members who opted for medical and dental members. for print will still receive a hard copy Starting this month we will replace in the post.

MDDUS INSIGHT / 3 These cases are based on actual calls made to MDDUS advisers and are published here to highlight common challenges within practice management. Details have been changed to maintain CALL LOG confidentiality. Consulting via social media I have a patient being treated for a Qchronic condition and we recently discussed switching medication and agreed to do some baseline bloods first before changing the prescription. The patient has now sent me a friend request via LinkedIn with a link to an article assessing a possible alternative medication. Is it okay for me to reply to this message with a link to another article showing there is no conclusive evidence supporting increased efficacy in the suggested drug? LinkedIn is a “professional” platform and the question is treatment related.

It’s best to be cautious about this type Aof communication with patients. GMC guidance on Doctors’ use of social media highlights that boundaries can become blurred when communicating through sites himself. It may be the mother would not want such as LinkedIn. It states: “If a patient her child to be informed of her request. If she Intoxicated contacts you about their care or other is content for this assessment to be professional matters through your private undertaken and he has capacity but refuses, patient profile, you should indicate that you cannot this would ordinarily be definitive. If he does An elderly patient recently attended mix social and professional relationships not have capacity and the mother maintains Qthe practice for an appointment and, where appropriate, direct them to your parental responsibility, the key issue is what having come from the pub. He was clearly professional profile”. The guidance also is in the child’s best interests to disclose. inebriated, smelling of alcohol, stumbling states: “social media sites cannot and slurring his words. The GP refused to guarantee confidentiality whatever privacy see the patient and asked reception to settings are in place”. We would advise that Keeping make another appointment for later in the you inform the patient that you do not use week. The patient was clearly not happy LinkedIn or any other social media platform insurance records and made a fuss in the waiting room. He is for clinical communication and provide a registered with the practice and has no range of options to contact you via the How long is our practice required to history of alcohol dependence. Are we practice. Qretain copies of completed medical allowed to refuse to see an intoxicated insurance reports? patient in such circumstances? Access to Insurance forms are covered by the Conducting a consultation with an AAccess to Medical Reports Act 1988 Ainebriated patient would clearly affect teen’s records and this allows for patients to request to your ability to obtain a detailed history and see a report or have a copy of a report up perform an appropriate clinical examination. A 13-year-old patient at our practice to six months from the date of it being In such circumstances it would be Qhas fallen out with his mother and is written – thus the practice would be appropriate to make an initial assessment of now living with his father. The mother has expected to keep copies of these the patient to consider whether other issues recently been in touch with the practice in documents for a minimum period of six are the cause of the patient’s presentation regard to an ongoing health issue with the months. Principle 5 of the Data Protection and whether it would be unsafe to allow him boy – but he no longer wants her to have Act 2018 is also relevant here, stating that to leave the practice in this state. It may be access to his healthcare information. What personal data processed for any purpose advisable to discuss the matter with practice is our legal position? shall not be kept for longer than is colleagues to determine whether the patient necessary for that purpose. Compliance may require further assessment/treatment Given the age of the boy it is possible with this legislation would suggest a for potential alcohol dependency. In the Ahe would be judged Gillick competent practice policy of safely disposing of event that the patient displays abusive with capacity to refuse disclosure of his insurance forms after six months. MDDUS behaviour, you may wish later to issue a personal medical information. We advise advises filing such reports independently of formal warning that such behaviour will not that the practice writes to the mother stating medical records so they can be easily be tolerated and could lead to removal from that, in order to consider whether information reviewed and kept for no longer than is the practice list. can be disclosed to her, the boy would need necessary in compliance with Data to be assessed by a GP regarding whether Principle 5. he is competent to make this decision for

4 / MDDUS INSIGHT PRIMARY CARE / Q1 2020 healthcare professional what are the Work-shadowing follow-up arrangements for the specific I’m a GP partner at a practice and patient. You could also discuss this matter Qhave been asked by a friend if his further with your LMC, who may have a daughter can shadow me for a few policy on the matter or would be able to sessions. She is in her final year at school advise you if similar instances have and is applying for medicine at university. Is occurred with other practices. this problematic? Work-shadowing arrangements are Non-clinical Anot uncommon but there are a race, pregnancy etc), it should be number of issues to consider. First a risk straightforward to advise the employee that chaperones assessment should be performed and her probationary period has not been recorded prior to such an attachment to successful. She should be given her notice Our practice recently discussed the ensure that the work environment is safe – which can be worked or paid in lieu – Qpossibility of chaperone training for for a visiting pupil. The Health and Safety along with any accrued outstanding holiday non-clinical staff. Is it a legal requirement to Executive has published guidance related pay up until the termination date. MDDUS undertake DBS checking for prospective to work-experience pupils (tinyurl.com/ members can request a template letter by staff wishing to act as clinical chaperones? uo65xfu). It is also crucial to consider emailing [email protected]. issues of confidentiality and consent. The In the first instance it would be pupil should be required to sign an Aimportant to consider whether it is agreement and given firm guidance that Cc’ing the GP appropriate for a non-clinical staff member personal patient details (even the fact that to act in this role. GMC Guidance on someone has attended the surgery) are Our practice is trying to reduce Intimate examinations and chaperones entirely confidential. Patients must be Qworkload and one thing that crops up states that a chaperone “should usually be asked for consent in advance (preferably in repeatedly is consultants copying the GPs a health professional and you must be writing) for a school pupil to be present in on bloods/histology results that they (the satisfied that the chaperone will: during a consultation and should also be consultants) have requested. Can we • be sensitive and respect the patient’s advised that they may change their mind at assume that the consultant will follow-up on dignity and confidentiality any time. Notices in the waiting room to results if abnormal? Could the practice be • reassure the patient if they show signs of indicate that school pupil placements may held liable for failing to inform the patient of distress or discomfort occur are also helpful. Pupils should be an abnormal result for a test that we did not • be familiar with the procedures involved in informed that they cannot expect hands-on request? a routine intimate examination experience and will only be observing on a • stay for the whole examination and be limited basis (e.g. no examinations). Finally, The doctor who initiates an able to see what the doctor is doing, if it is important that the whole practice team investigation is ultimately practical are comfortable with the arrangements to responsibleA for following it up • be prepared to raise concerns ensure the pupil is appropriately supported and advising the patient if they are concerned about and supervised. accordingly (or making the doctor’s behaviour or clear alternative actions.” arrangements) but The guidance also Probationary there are often cases states that a “relative or in which continuity and friend of the patient is employment coordination of care not an impartial are required. The observer and so would We hired a medical receptionist on a GMC highlights that in not usually be a suitable Qsix-month probationary basis but delegating care you chaperone, but you there have been a number of issues arising must ensure that you should comply with a in that period. These include not complying “share all relevant reasonable request to have with practice protocols and procedures information with colleagues such a person present as well despite being given repeated training. She involved in your patients’ care as a chaperone”. MDDUS would has also stated that she will not be available within and outside the team”. In the suggest that you review the guidance as a to cover annual/sickness absence which circumstance described, the consultant whole to assist in your decision making in was clearly outlined in her interview. I have initiating the investigation is likely to be this matter – but should the practice still discussed these concerns and informed her responsible for reviewing the patient. wish to consider the use of a non-clinical that at present we will not be offering her a However, as this information is being chaperone it is important that you are able permanent employment contract. Are we provided to a GP in the practice it should to clearly explain and justify this decision. within our rights? not be simply ignored – especially if urgent We would also advise that you ensure the action is required. It would be difficult to person is appropriate and reaches the An employee with under two years’ defend adopting a specific policy not to above standards. Most health professionals Aservice does not have unfair dismissal review copied correspondence. Ultimately, will have already undergone DBS checking rights. As long as there are no protected if there is any confusion, it would be and we would anticipate that non-clinical characteristic issues (such as disability, sex, necessary to clarify with the originating chaperones would also require vetting.

MDDUS INSIGHT / 5 SAFETY AVOIDING WORKPLACE VIOLENCE Helen Ormiston Practice adviser at MDDUS

HERE has been much discussion in LONE WORKING primary care around zero tolerance Do you have staff working alone policies and the uneasy line between in the surgery or conducting visits meeting the needs of the patient unaccompanied? If so, it is important to and the legal obligation to provide consider what reasonably practicable safe places of work for staff. As attacks on measures can be put in place to address Thealthcare staff increasingly make their additional risks. For example, if staff way into news headlines, it is important work alone during extended hours, can that managers are proactive in reducing the these appointments be bookable only in potential risks facing employees. advance? The use of security cameras at From a health and safety perspective, the surgery entrance may be useful, and every practice should have a comprehensive consider also door security so patients policy setting out the identified risks to cannot walk in unexpectedly. In addition, staff (and the public), what steps have been would it be possible to limit known taken to eliminate or minimise them, and aggressive patients from accessing these who is responsible for overseeing the safety appointments? Review proposed home of all those within the practice. visits where possible to try to ensure they As with many health and safety are allocated to appropriate clinicians obligations, the starting point in addressing (trainees may build up their experience required and recommended actions is before visiting more difficult patients) to conduct an adequate risk assessment. and act on MAPPA (multi-agency public The basic purpose of the risk assessment protection arrangements) warnings. is to identify hazards, evaluate risks and Do clinicians need to attend in pairs or implement, monitor and review measures liaise with police or other agencies before to reduce the risks – in this case potential undertaking a home visit? aggressive behaviour to staff and others. The Health and Safety Executive (HSE) has specific TRAINING guidance on assessing workplace violence Do staff receive appropriate training, within a health and social care setting. including basic techniques in managing TECHNOLOGY The following areas are likely to challenging behaviour or de-escalation, Is appropriate equipment available, such be relevant when undertaking a risk with greater training for those in higher as panic buttons or alarms? Ensure that all assessment for GP premises. risk situations? Use protected time sessions staff understand how the alarms work: for to update training. example is the alarm audible or silent, does PHYSICAL ENVIRONMENT This training could include causes it alert the police directly when activated • Are access ways well-lit and visible? of violence, recognising warning signs, or must a member of staff contact 999? Are there good lines of sight? One study interpersonal and communication skills, Ensure alarms are tested and serviced in reported a 50 per cent reduction in violent de-escalation techniques and incident the same way as fire alarms. incidents in A&E as a result of design and reporting procedures. signage changes. ACTION POINTS • Consider the height and width of POLICIES AND PROCEDURES • Adopt a risk assessment approach to the reception desks and whether patients can Are there appropriate policies and management of workplace violence and reach over to staff. procedures in place for handling incidents, aggression that takes into consideration • CCTV cameras in the surgery and emergencies and particular high-risk the individual circumstances of a case. surrounding the buildings can act as a patients, and dealing with threatening • Ensure that all incidents of work-related deterrent and recordings can be used as patients? These may include the use of violence are recorded and reported evidence if needed. warning letters and acceptable behaviour through relevant health and safety systems • Are telephone calls recorded? Call agreements. Any warning or behaviour and, if appropriate, to the police. You may recording may substantiate an employee’s contract should always be made based on need a police incident number to refer a concerns about an abusive caller. an individual patient’s specific needs and patient to the challenging behaviour unit. Recordings can also be used in staff not just as a blanket policy. GP practices are • Have a clear and comprehensive policy in training to review whether a call may have often tolerant of unacceptable behaviour place for dealing with aggressive or violent been handled differently. from patients because they are unwell patients, including the steps to be taken • Is the reception desk visible to or within or frightened – but do not wait until when considering removing such patients earshot of other staff, who may be able to behaviour escalates before proactively from a practice list. Review the GMC’s provide support if necessary? addressing the concerns. It is not unusual guidance and your contractual obligations • Review the layout of consulting rooms for non-clinical members of staff to bear regarding ending a professional and select furniture and fittings that are the brunt of a patient’s unhappiness; relationship with a patient. Take care with difficult to use as weapons. Explore whether ensure staff are fully supported when they documenting an incident – keep to the staff are able to leave the room quickly if raise concerns about aggressive or abusive facts and maintain a professional tone in needed, and how best to do so. behaviour. all descriptions.

6 / MDDUS INSIGHT PRIMARY CARE / Q1 2020 RISK DATA CONCERNS WHEN TEXTING PATIENTS Alan Frame Risk adviser at MDDUS

EXT messaging patients has become consideration as to what may happen if marketing, where explicit consent from almost routine in healthcare today. the information is misused. Some clinical the patient would be required (see below). Even the GMC now recognises that information by nature is especially A results notification would also be texting “can be convenient and sensitive, such as issues relating to sexual legitimate but only the fact that a result is supports effective communication or mental health, and in any case all now available. Transmission of actual test between doctors and patients”. However, health information is classified as “special results by text and other specific clinical Trobust processes are still needed to category data” under GDPR, which demands information is possible but the practice monitor and control both message content even greater security measures to be in would have to identify a specific “special and intent, as well as protect patient place. category condition” for processing and confidentiality. The Information Commissioner’s Office communicate their intention under a Enactment of the General Data (ICO) has produced general guidance that published privacy notice or statement. Protection Regulation (GDPR) has raised health professionals should consider and The ICO also emphasises that attaining concern among GPs about what exactly follow in the provision of a text messaging individual patient consent to send actual is permissible to send to patients by service to patients. Specific advice can also test results would be “good practice”, text. Text messages are transmitted on be obtained by phoning the ICO advice line paying particular attention to accuracy public phone networks and are therefore on 0303 123 1113. and security, and taking reasonable steps potentially insecure. They can also be read The starting point for data controllers to ensure that mobile numbers are kept by unintended others. A clinician may not is to identify a lawful basis under GDPR for up to date. Otherwise a foreseeable data be responsible for a message once received the processing of all personal information, breach could occur. by a patient but it is useful to remind as well as the “special category condition” and encourage patients to ensure their for health information. Once established Can “service update” messages be texted to phones and devices are only accessible by it should be set out in a privacy notice all practice patients? This could include, individuals with permission to view their and publicised widely within the practice, for example, “the clinic will be closed for personal sensitive information. on its website and social media pages, as training next Tuesday afternoon” or “the Before examining specific GDPR appropriate. A practice intending to use practice will now be open until 7pm on considerations, it is important to reinforce text messaging to contact patients must weekday evenings”. Although not patient- that care should be taken with any text clearly set this out in its privacy notice in specific, such texts would be viewed as messages that contain sensitive clinical a “granular” and “meaningful” way. This service update messages and therefore information. This may relate to the type means clarifying the specific purposes for permissible. The intention is to inform of information being transmitted (e.g. a which you intend to contact patients and patients about important service changes specific clinic appointment or mention not deviating outside those communicated or updates to prevent inconvenience of a condition) but it also requires parameters. and maintain the smooth operation If the above process is followed, there of the service. While specific patient is no additional requirement under GDPR consent would not be required, the ICO to obtain individual patient consent advise that a descriptor of such types of to send patient-specific text messages. communication should also be included in However, the ICO confirms that obtaining your privacy notice. such consent would still be regarded as What is considered direct marketing “good practice”, and this is more aligned to under GDPR? This is defined as the current regulatory guidance from the GMC. “promotion of a service, whether for Looking at some specific advice profit or not” and under GDPR will require requests that MDDUS has received explicit opt-in consent by recipients. Some since the introduction of GDPR can examples of what could be construed as hopefully provide clarity on complex direct marketing include setting up and issues that might be open to testing and advertising a new diabetes clinic for all interpretation. patients on the practice database with this diagnosis, or promoting a travel Is it acceptable for a practice to send clinic to provide holiday/travel advice and appointment reminders and other vaccinations. patient-specific information, such as a It is again also important to remember chronic disease recall alert? The answer your professional obligations when it here is ‘yes’, as long as the message is comes to protecting patient confidentiality patient specific and a “reminder” rather and to review appropriate guidance, than “promoting a service”, which including the GMC’s Confidentiality: good may come under the category of direct practice in handling patient information.

MDDUS INSIGHT / 7 FEATURE / PROFILE

DIYAn award-winning HEALTH project aims to help ease demand on an overburdened healthcare system – and much more

OWER Hamlets in London faces A significant proportion of primary some tough challenges when it care demand comes from patients comes to healthcare. attending for self-treatable conditions. This inner city borough has the An estimated 27 per cent of patients seen highest rate of child poverty in in GP appointments could actually be the capital at 43 per cent. Healthy getting necessary advice elsewhere. Figures life expectancy in men is among the lowest from 2016 show that minor conditions in the country at 61.3 years compared with and illnesses were responsible for T63.1 years nationally. The borough also has approximately 57 million GP consultations high premature death rates from circulatory and 3.7 million A&E attendances, costing the disease, cancer and respiratory disease, along NHS more than £2bn – resources that could with high rates of diabetes, particularly be better employed elsewhere considering among its Bangladeshi community. the increasing demands of an ageing stakeholders to implement a peer-to-peer Addressing these challenges on a daily population with complex morbidities. learning programme. This was the genesis basis is Bromley by Bow Health (BBBH) – a Khyati discussed the issue with her of DIY Health: 0-5. partnership of three surgeries located in practice partners. “Looking on a borough- DIY Health is delivered in eight to the heart of Tower Hamlets. It is affiliated wide level we found children nought to 12 two-hour sessions, catering for up with the pioneering Bromley by Bow Centre: five were behind some the highest spend to 12 parents per session. Topics covered part church, part charity, part community in A&E attendances and the majority of include management of fever, diarrhoea hub, with a reputation for innovation and these were for minor ailments. But when and vomiting, skin conditions, coughs experimentation in social care. we looked at the wider data we found it and colds, ear pain and feeding. The It was here in 2013 that Dr Khyati Bakhai wasn’t just a local problem but a UK issue. programme also utilises play specialists to started her career as a GP partner, nine So we decided to create something that involve the children and ensure childcare months into a Darzi Fellowship for clinical could be used nationally and replicated in is not an issue. leadership. An ideal choice, as this would different settings.” Over 300 families have taken part in prove the genesis of an innovative new DIY Health since 2013 and the scheme has programme that could in future help ease CO-PRODUCTION also trained several parents who can now the burden on primary care provision In her project work as a Darzi Fellow, facilitate the programme. across the UK. Khyati employed a development Says Khyati: “Once we piloted the methodology known as co-production. programme we started seeing huge SELF CARE Rather than simply consulting on what’s benefits and not just in children’s health. Just after starting at BBBH’s St Andrew’s needed, co-production involves users It reduced isolation and parents were Health Centre, Khyati noticed that parents of (patients) directly in the design, delivery able to talk to each other about their own children under the age of five were frequently and evaluation of a service. It places wellbeing. It addressed problems that we reattending for minor ailments that them in partnership with professionals had not even necessarily identified.” could easily be dealt with at home, such as using “participatory action learning Evaluation of the next phase conducted diarrhoea, fever and viral coughs and colds. techniques” to ensure the effective transfer in partnership with the Anna Freud Centre “I started enquiring about this with of knowledge, skills and capabilities. and Professor Monica Lakhanpaul and some of the patients,” says Khyati. “And The method has been shown to improve Carol Irish working with UCLPartners they said either they didn’t have the outcomes and intervention effectiveness. showed an increase in knowledge, knowledge or the confidence or just “The partnership supported the facilitation confidence and skills to manage a wide someone else to speak to about these of focus groups and we worked with patients range of health issues for all parents issues, and this was what was often driving at the outset to determine exactly what was involved, and high levels of co-production them to come and see the GP.” needed and in what context,” says Khyati. “The throughout the programme. Quantitative This led Khyati and her colleagues to patients themselves then helped us pitch for results revealed a 36 per cent reduction recognise that more needed to be done funding.” in attendance for minor ailments to GPs, to help parents and carers manage their A six-month pilot was costed as part of emergency departments, out-of-hours children’s health at home and to know the Tower Hamlets CCG Innovation Bursary clinics, and walk-in centres in the 12 when to seek further help. It’s a challenge Fund. Khyati worked with Patient First months following the programme. reflected across UK healthcare. manager Emma Cassells, parents and other Reducing the burden on primary care

8 / MDDUS INSIGHT PRIMARY CARE / Q1 2020 Main picture: Dr Khyati Bakhai and Nasim Hafezi. Below: DIY Health team attending the BMJ Awards (from left): Nasim Hafezi, Surayia Uddin, Clara Baroi, Khyati Bakhai and Emma Cassells

not just about health but also community “We found children – about helping each other. “Most of the nought to five were parents know what they are supposed to do but just need some reassurance. It’s about behind some of the sharing other parents’ experiences, their stories – especially now in this day and age highest spend in A&E when people may not have family nearby. attendances and the “One of our parents said to me: ‘this is the only place where I feel I can talk about majority of these were my children without being judged’. That is so important.” for minor ailments” It’s these wider benefits that contributed to DIY Health being honoured in the 2019 BMJ Awards as Primary Care Team of the Year. The judges said they were particularly impressed by the way in which the project services has been an important outcome working as a patient assistant in reception. empowered and connected local parents. of the programme but was not the prime “An email went around the practice to “There were obvious immediate benefits motivation for Khyati. “The aim is to get see who might be interested in DIY Health,” for parents, their children and health people the most appropriate help in the she says. “I was a bit bored with what I was providers. And also a long-term ripple most efficient way. We have seen a change doing to be honest. Something about it effect into the local community.” in people in that they are more confident really interested me.” BBBH are keen to spread the DIY Health accessing resources online and minor Nasim worked at first with a nurse but ethos of co-production and participatory ailments schemes directly through the now co-facilitates DIY Health sessions with learning across the UK and have produced pharmacy.” other non-clinical staff. a free toolkit (available at https:// “In a way I think it’s better to be non- uclpartners.com/diy-health-toolkit). SPEAKING THE LANGUAGE clinical because you speak the same Khyati says her top advice for anyone Another unique characteristic of the language. You’re not making everything undertaking a similar approach is not to programme is its multidisciplinary clinical. But if there’s any problem, if I’m not start from scratch but to reach out. approach. Says Khyati: “It started off sure how to answer a question, I know there’s “Get in touch with us or anyone who with medical professionals, then health a clinician I can go to. That’s never an issue. is doing something similar. Start from a visitors and now we have non-clinicians “It’s a very informal session. Not us point they have left off so that we are not facilitating these sessions. We are giving standing in front of a blackboard and all reinventing the wheel.” our non-clinical staff a wider role in saying you must do this. It’s the parents Khyati can be contacted via email at improving people’s health – and this who decide what topics they want to [email protected] improves staff satisfaction.” discuss for the following week.”

MAIN PHOTOGRAPH: DOMINICK TYLER; INSET: HARRY RICHARDS HARRY INSET: TYLER; DOMINICK PHOTOGRAPH: MAIN Nasim Hafezi joined BBBH four years ago, Nasim also insists the programme is Jim Killgore is managing editor on Insight Primary Care

MDDUS INSIGHT / 9 FEATURE / PATIENT SAFETY MAKING A

SEAIs your practice truly CHANGE learning from adverse incidents? MDDUS senior risk adviser Liz Price offers some reflections on SEA

IGNIFICANT event analysis (SEA) is now and safer protocols adopted as a result of such (hopefully) embedded as an ongoing process reporting can encourage future engagement. Reviewing which supports complaints handling and acts the ease of reporting is also important: achieving a as a collective learning exercise within general balance between simplicity and gathering appropriate practice. But when was the last time that you data is crucial. took stock of how much value your practice is getting Sout of the process? WHO DO YOU INCLUDE IN THE PROCESS? Many of the SEAs we see at MDDUS in our role Some clinical incidents may be too sensitive for assisting members with potential medicolegal cases discussion in a wider team setting, but should an are more of a description than analysis. A lack of SEA involve non-clinical systems it is essential that analytical rigour in SEAs, if routine, can lead to poor a suitable member of the admin team is involved engagement in the process with much less learning to ensure that any changes are sensible and do not and a reduced impact on patient safety. If your practice create additional risks. Alternatively, clinical SEAs or is sleepwalking through SEAs, consideration of the admin-only SEA outcomes can be briefed to the wider following can help. team at regular practice meetings. Either way it is important to ensure changes are properly understood HOW ARE EVENTS TARGETED FOR ANALYSIS? (and embraced) by the wider team. Factors at play here include the use and effectiveness Routine SEA meetings involving the full team should of your incident reporting processes. Does the team include a range of topics or potential risks (errors) over understand what to report? Are low level incidents, a set period of time (e.g. a year cycle). This will ensure near misses and ‘good catches’ being collected as well that no one group feels alienated or unengaged in the as significant incidents for thematic review? There process. is some evidence that unless there is a significant proportion of these incidents reported, it may be that HOW IS THE SEA MEETING STRUCTURED? your processes are not sensitive enough. Many practices use similar styled templates for Among additional benefits in capturing lower structuring conversation and analysis around level but repetitive incidents is the identification of significant events. A structured approach is essential training needs and also a reduction in unnecessary but it can often end up being used as a ‘documentation’ follow-up activities. Practices should also consider tool rather than an in-depth ‘learning’ tool. A highly who reports incidents. Are the same people putting structured conversation in the context of a busy agenda forward the same events for discussion or do SEAs cover may disincentivise discussion after “high-level factors” the full range of services/activities undertaken by the are identified. Staff may be reluctant to address other practice? Does your organisational culture support self- contributing factors and may feel pressure to “move nomination? Staff who feel unsupported are unlikely onto the next agenda item” or “wrap the conversation to report an incident in which they were involved. up”. There may be a reluctance to express any implied (or It can be helpful to nominate a member of the team implicit) criticism of others, or to draw others into the to review all reported incidents on a regular basis mix by expanding the depth or breadth of the analysis. in order to identify themes. Particular systems or A good chair should be able to manage the time spent protocols associated with lower level incidents can then on each agenda item, whilst ensuring that enough be targeted for analysis, and solutions presented for a exploratory questions are asked in each area of analysis. sense-check at team meetings. Highlighting efficiencies It’s useful to collect as much information as possible

10 / MDDUS INSIGHT PRIMARY CARE / Q1 2020 MAKING A SEA CHANGE

beforehand in relation to the event(s) in question, in Identifying such underlying issues can often be order to maximise the quality of discussion. This could uncomfortable and challenging to resolve. They may include more detailed written statements, copies of relate to deficiencies within practice management/ current policies or other records, as appropriate. leadership or ingrained behaviours created by stress/ overload – but such causal factors will likely lead to IS THE MOST COMPREHENSIVE future incidents if not recognised and resolved. LEARNING EXTRACTED? Often only superficial learning and training ARE OUTCOMES BEING MAXIMISED? opportunities are identified through the SEA process. To ensure that any lessons learned from incidents What went wrong may be put down simply to: “the are cascaded properly, the practice should agree a process or protocol wasn’t followed” or “the person mechanism by which staff not directly involved in should have asked for advice from a colleague at the an SEA still receive an update. Any amendments to time of the incident”. Subsequent learning is then protocols or practice systems should include clear noted as: “the protocol should be followed in these information about the efficiency, effectiveness or circumstances” or “in future a GP should be asked to patient safety gain from the proposed change, as this speak to the patient if they present in this way”. Such is likely to encourage compliance. conclusions may be true but unless “why” questions Sometimes, research or audit is required to assess are asked, many incidents are more likely to reoccur. the extent of any issues identified, or further training This is because in most scenarios there will be other will be necessary to support improved practice. It is underlying factors that contributed to the adverse important to agree a timescale for completion, and incident. Such factors usually range across: an individual should be appointed to make sure it • People – the specifics of the patient or the team happens and is reported back. member involved. At the end of the review, an anonymised written • Activities – the task(s) or process that the individual record of the analysis, including insights gained, (or team) were engaged in at the time. lessons learned and actions agreed should be • Environment – the setting or situation within completed and retained securely. It is often useful to which the incident occurred. share an SEA with the patient as part of a complaint Asking “why” multiple times will help draw each response to show evidence of quality improvement strand of an investigation to its natural start point. (e.g. as part of a CQC inspection under KLOE2). Where an Indeed there is evidence that asking “why” five times is event led or could have led to patient harm, an SEA can the optimal strategy to achieve deeper learning and a be used by GPs as evidence of reflective practice for the root cause. purposes of appraisal or revalidation. Exploring the contributory factors more fully should Should you need assistance in reviewing your lead to findings such as: “the protocol was not followed incident reporting system, members can access our because the individual was under too much pressure” incident reporting checklist in the training and CPD or “the GP was not consulted for advice because the pages at mddus.com. MDDUS advisers are also available receptionist was too scared to approach them”. In the to review anonymised SEA draft reports, once the latter example, asking why is likely to identify whether investigation has been completed. Getting this right the receptionist needs support to be more assertive, will set your efforts off in the right direction. or whether the GP needs to adjust their manner or response to interruptions. Liz Price is senior risk adviser at MDDUS

MDDUS INSIGHT / 11 CASE STUDY• DIAGNOSIS PERFORATED APPENDIX

DAY ONE DAY FOUR A 19-year-old student, Daniel, presents at the Daniel is brought to A&E by his flatmates in “agony” and is campus surgery complaining of abdominal diagnosed with appendicitis. A note of the initial assessment cramps and vomiting. His flatmates have records a three-day history of abdominal pain, abdominal recently suffered similar symptoms. He is distension, generalised tenderness and absent bowel sounds. attended by Dr J and reports having been sick around 10 times (but less frequently that morning), along with some episodes of diarrhoea. Dr J notes that the patient is apyrexial with a heart rate of 68 and respiratory rate of 14. The GP examines his abdomen and notes: Abdo – soft. Mild generalised tenderness. DAY FIVE Dr J concludes that Daniel is likely to be Daniel is taken to theatre and undergoes an open suffering from gastroenteritis and advises him to appendicectomy. The surgeon finds a perforated appendix with take paracetamol and drink plenty of fluids. He copious pus in the abdomen. Daniel has a difficult recovery with is also instructed to seek further medical care if complications including a post-operative ileus, pleural effusion the symptoms do not resolve or he becomes and hospital-acquired pneumonia. more unwell.

DAY 13 Daniel is discharged from hospital. His parents later contact a solicitor and a letter of claim is sent to Dr J alleging breach of duty of care in failing to consider a diagnosis of appendicitis. It is alleged that this led to a delay in referral for further assessment and treatment, resulting in a perforated appendix requiring invasive surgery and a risk of associated complications.

MDDUS seeks expert opinion on both reasonable skill and care. required in any event and the complications breach of duty and causation in the case. In The primary care expert does however could not be attributed to delayed referral. his response to the claim, Dr J highlights comment in his report that a more detailed MDDUS prepares a letter of response that he did in fact consider a diagnosis of record of abdominal findings would have repudiating the claim on the basis of the appendicitis when Daniel presented with been ideal, such as whether there was any expert reports. Notice is later received that abdominal pain. He carried out an guarding and rebound tenderness in the right the patient has abandoned his claim and abdominal examination and checked heart iliac fossa and whether bowel sounds were the case file is closed. rate, respiratory rate and temperature, as normal. recorded in the consultation notes. Dr J’s In regard to causation (the consequences KEY POINTS position is that he felt that a diagnosis of of breach of duty), expert opinion from a • Ensure medical notes reflect key detailed appendicitis was unlikely on the basis of general surgeon concludes that Daniel was observations upon which clinical decisions these findings. in the early stages of appendicitis when he are based. The GP expert opines that it was presented to Dr J but no obvious signs were • Document significant differential reasonable for Dr J to conclude that Daniel’s likely to have been present at that point. The diagnoses considered and why they have reported symptoms were consistent with expert considers that appendicitis would not been discounted. gastroenteritis rather than appendicitis, and have been diagnosed at this stage, even if • Offer patients clear safety-netting advice that the care provided was in keeping with the patient had been admitted. As such, an on when to re-attend or seek emergency that of a reasonable GP, exercising open appendicectomy would have been care.

12 / MDDUS INSIGHT PRIMARY CARE / Q1 2020 ETHICS IT’S THE SMALL THINGS Deborah Bowman Professor of Bioethics, Clinical Ethics and Medical Law at St George’s, University of London

HEN I first became interested in medical ethics, it was an issues-led field that was predominantly concerned with ‘big questions’. The relatively few books that existed had titles Wsuch as Matters of Life and Death. There were no syllabi nor any agreed curriculum content, but the lectures I attended were commonly concerned with a triad of abortion, euthanasia and reproductive ethics. These are, of course, important. Yet, early on, I became interested in the intersection of ethics and the small things. For example, those precious initial moments in an encounter that set the tone and allow for trust, dignity and humanity to flourish, how we adapt in pressured environments to queries or interruptions, how constructively we can disagree and the tone of our communication with others. I wrote a lot about the “ethics of the everyday”, largely absent from curricula and textbooks, but integral to healthcare. conversation. I debated whether to go over I have been thinking a lot about the “The letter was an to the Breast Centre and speak to them small things and the big challenges that in person whilst at work, or whether it they can present for staff and patients. unavoidable small was better to make a telephone call from A few weeks ago, I received a letter from thing; a consequence home. The task hung over me and I was ‘the NHS’. It advised that an appointment apprehensive when I passed the unit as had been booked across the road from of the complexities I walked through the hospital. I knew my office for breast screening. The letter though that this ‘small thing’ was no one’s explained why this appointment was and challenges of fault and I had to acknowledge that truth valuable, talking about age, risk, early running a national in my response. detection and improved prognosis. Eventually, I rang the unit. It was not As some readers will know, this letter was screening system” the conversation for which I hoped. I received by a woman who no longer has was reminded by the staff member that breasts and, so far, has received two and a screening slots are precious and, although half years of treatment for breast cancer. it was a fortnight until the pre-booked I was, in a response that is increasingly alert to avoid being in this position in the appointment, asked why I had waited a few familiar when I think about illness, both first place. days to get in touch. I was asked twice if I rational and emotional. I appreciated that I knew enough not to do anything was “sure” even as I explained that I have it was an automated letter and no one’s immediately but to sit and process my had a radical bilateral mastectomy. No fault or responsibility. I understood that response; to attend both to the rational one knew whom I should contact to avoid for many, the letter would be welcome and and to the emotional. After a few days, I being invited to future screening in the the ease of a pre-booked appointment began to wonder about the member of hope that I could save the NHS time and appreciated. In a complex and resource- staff who would take my call when I rang resource by preventing further letters and constrained system, it isn’t efficient or to explain that I would not be attending pre-booked appointments. perhaps even possible, to identify those the appointment. He or she would have When I put down the phone, I reflected who might be considered exceptions. no idea about my circumstances, or that on “the small things”. The letter was Yet, I was also upset. The letter was I have deliberately avoided having any probably an unavoidable small thing; a stark plunge into dark places. Its clinical care at my own hospital. Rather, I’d a consequence of the complexities unexpected arrival was an unavoidable encounter someone likely to be working and challenges of running a national reminder that I was relatively young in a pressured environment and juggling screening system. However, the response when diagnosed, that I had late stage myriad demands. of another person to my call was a small disease with a poorer prognosis, that I was I wanted to explain why I wasn’t thing that could have been different. The physically different from most women, coming, but I knew I needed to do it in conversation, imbued with officiousness, that I was frightened about the future, a way that was calm, factual and kind. I irritation and misunderstanding, reflected that I felt ashamed about perhaps having understood that the person I contacted ethical choices. It could have made all ‘missed something’ before I was diagnosed was not responsible for, or even aware the difference. There was nothing “small” and that maybe I should have been more of, my personal response. I rehearsed the about it.

MDDUS INSIGHT / 13 Addenda OBJECT OBSCURA Heartstrings – digital image THIS swirling arrangement of cardiac fibres in the left ventricle was produced using a type of MRI known as diffusion tensor imaging (DTI). The non-invasive technique tracks the diffusion of water molecules in the myocardium, revealing valuable information about the structure of the heart in a non-invasive way. It allows scientists to model the structure of cardiac muscle cells and how certain pathologies, such as ischemia, can cause this to change. FILM CHOICE

PHOTOGRAPH: WELLCOME WELLCOME PHOTOGRAPH: Dark BOOK CHOICE Waters Directed by Todd Haynes, UK 2020. Starring Mark The Body: A Guide Ruffalo, Anne Hathaway for Occupants. By Bill Bryson A SHOCKING true story of corporate greed wreaking Transworld, hardback, £25.00 2019 untold environmental damage is Review by Dr Greg Dollman, Insight editor at the heart of this legal thriller. Ruffalo stars as real-life corporate defence attorney Rob I MUST admit I was a little sceptical at first. facts (the record for staying awake is 11 days, Bilott, who went from advising How could anyone, even Bill Bryson, keep me 24 minutes), the history lessons (pioneers of businesses on how to pollute engrossed throughout nearly 400 pages of a medicine along with the ‘firsts’), refresher legally to suing one of the lay description of the human body? There are courses on immunology, microbiology, world’s largest chemical only so many “we blink fourteen thousand nutrition (you name it, it’s mentioned) and of companies, DuPont, for times a day” and “the body makes millions of course the references (over 40 pages of them). dumping toxic sludge into a red cells every few seconds, and discards one I anticipate that experts will note small town river. billion every day” facts that I could appreciate. factual inaccuracies, unsurprisingly given Ruffalo puts in one of his best I was wrong. Within the first few pages, the volume and detail within the book. performances yet as the Bryson describes the human body as “a warm Remarkably, however, Bryson provides determined lawyer who wobble of flesh” and I was hooked. considerable facts and figures, in a very responds to a plea for help from The chapters whistle-stop their way entertaining format, for a non-medical a West Virginia farmer whose through the anatomy and physiology of audience. cows have been dying in the body, reminding us how we come to The Body provides mysterious circumstances. At be, what makes us who we are and how we a comprehensive great personal cost, Bilott live – marvelling at what ‘goes right’ and account of something doggedly investigates DuPont considering what can go wrong. that I know reasonably and uncovers a corporate Bryson’s descriptions are witty and astute: well and yet managed cover-up that is breathtaking in he observes that, considering the nature of to keep me turning its disregard for the environment the skin’s stratum corneum, “all that makes the pages – and and the health of the town’s you lovely is deceased”, and explains how we smiling while I did people and animals. are infected with viruses and colds on being (contracting the This is a story that deserves “exposed to others’ leakages and exhalations”. orbicularis oculi to be widely told and, while it is The Body surely contains something for muscle in each often intense and infuriating, everyone. There are the bizarre facts (Bryson eye to make them director Todd Haynes never lets notes the difference in bowel transit times sparkle, as Bryson the story drag. between men and women), the ‘pub quiz’ tells us).

14 / MDDUS INSIGHT PRIMARY CARE / Q1 2020 VIGNETTE Margaret Fairlie (1891-1963) First female professorial chair in Scotland

DUNDEE prides itself as a city of discovery dealt with patients across a wide age and in recent years has worked hard to spectrum and enjoyed all aspects of it. As honour those of its citizens who have an obstetrician, she helped set up ’s contributed to that name. Today in Slessor first antenatal clinic. One matron asked her: Gardens, behind the imposing Caird Hall, “Do you think if all the babies you delivered you will find a walkway paved with bronze were laid top to tail they would reach from plaques. Amongst these is one to Margaret Dundee to Perth [some 22 miles]?” should have almost automatically made Fairlie. As well as a short biography, the “Yes – and heading for Scone [another her eligible for the chair in obstetrics plaque depicts less obvious clues about her 2.5 miles]!” was Fairlie’s quick reply. and gynaecology. However, it took the life and career – a frame of sea holly and As for her interest in the novel treatment University authorities four years to come wheat, a glimpse of the Eiffel Tower and a of gynaecological malignancy, this was to terms with appointing a woman. stylised atomic structure of radium. sparked by her visit in 1926 to the Marie Perhaps she was a victim of the political Margaret Fairlie was born in Angus and Curie Foundation in where she difficulties ongoing between Dundee and grew up on a farm near Arbroath –hence learned about the clinical applications St Andrews Universities at the time, but it the plants framing her plaque. She studied of radium — hence the Eiffel Tower and is also thought that the then Principal of St medicine at the University of St Andrews atomic structures on her bronze plaque Andrews was particularly averse to the idea and University College, Dundee, graduating in Dundee. On her return, she pioneered of a woman professor. during the First World War. After holding its use in Scotland and conducted careful She was finally appointed to her chair various clinical posts in Dundee, Perth and long-term follow up of her patients. Thirty in 1940, with the strong backing of the , she worked Directors of . at St Mary’s Hospital in At the time of her retirement in Manchester, where she 1956, she remained the only female received much of her Scottish university professor. It specialist training. She would be another two years before returned to Dundee in At the time of her retirement the University of Edinburgh would 1919, where she would in 1956, she remained the only appoint its first woman to a chair spend most of her and a further 22 years before remaining career. There, female Scottish university Glasgow would follow suit. she ran a consultant professor In her retirement Margaret was a practice for gynaecology, keen gardener and an enthusiastic and the following year traveller. It was while in Florence in started teaching at the the summer of 1963 that she took ill Dundee Medical School. for the last time. She returned home In the mid-1920s, she joined the staff years later she would remark: “One aspect and was admitted to her former hospital of Dundee Royal Infirmary and in 1936 of my work which has given me especial where she died soon after. Today there is was promoted to Head of Department satisfaction and delight has been my that bronze plaque on Dundee’s Discovery of Obstetrics and Gynaecology. Her continuity with the patients who attend Walk, which includes words from one of appointment, however, was not met with the radium follow-up clinic... some of her patients: “ ‘She gave me the will to live.’ universal approval, and one male colleague whom have been coming for twenty years... Surely no higher tribute could be paid to a was disgruntled that the post had been The atmosphere at this clinic is one of practitioner of medicine.” awarded to a woman. trust, gratitude and mutual affection.” Although a gifted and diligent teacher, Her students, her colleagues and her Allan Gaw is a writer and educator from Scotland she also pursued an active clinical career. In patients found much to praise, but perhaps addition to her core work at the infirmary her main claim to fame was to become SOURCES in Dundee, Fairlie was visiting gynaecologist Scotland’s first female professor. This, • Baxter K. Archives. to all the hospitals in Angus and in the however, was not straightforward. In 1936 • Richardson S. Glasgow Herald, 20 April 1956. north of Fife. Like all in her specialty, she her appointment as head of department • Obituary. Glasgow Herald, 13 July 1963.

MDDUS INSIGHT / 15 MDDUS TRAINING COURSES – SIGN UP NOW! GPs and practice managers can learn practical tips and skills around key risk areas relating to professionalism, complaints handling, conflict management, social media and more in MDDUS’ 2020 training events.

Upcoming courses, taking place in Glasgow and London, include: • Professionalism: fulfilling your duties Glasgow, 29 April; London 28 May as a doctor – London, 23 April • GP risk training day – Glasgow, 12 May; • Practice managers training day: London 10 June. managing conflict to reduce practice risk –

For more information or to book, visit www.mddus.com/training-and-cpd/events or email [email protected]