Out-of-hours primary care, or ‘unscheduled care’, is well-known to be high risk for a number of reasons. For example, in an unscheduled care setting, telephone triage is the norm, meaning that GPs begin their consultations with limited information.
Hours can be long with a high number of patients to see, who often have no prior relationship with the GP, presenting with conditions that can be more complex and acute than those seen in scheduled consultations, and who are more likely to be tired and distressed.
There is also limited support, with fewer ancillary staff available and reduced access to patient records, investigations and secondary care.
Claims from unscheduled care
Seeing an unfamiliar doctor in a stressful environment can help to explain why patients who see a GP in unscheduled care may be more likely to take action against them if they experience an adverse event. In my experience at Medical Protection, claims arising from unscheduled care can also be more costly than those arising from other specialties.
We have seen two cases, which both settled for more than £5m each, involving GPs working in unscheduled care who did not arrange admission of babies with respiratory difficulties. The babies subsequently suffered cardio-respiratory arrests and were left with lifelong care needs. In another claim, there was a delay in an admission to hospital involving a patient with meningitis, leading to severe physical disabilities. This case was settled for around £3.5m.
Steps to make unscheduled care safer
Below are a few simple steps for GPs that can help make unscheduled patient care safer and reduce the risk of complaints and claims:
Show sympathy
Take active steps to show sympathy, and understand and acknowledge the patient’s situation from the outset, before starting on directed history-taking.
Instead of beginning the consultation with: ‘sorry to keep you waiting’, you may like to consider saying: ‘I see you’ve been waiting for 45 minutes. That’s never nice when you’re feeling unwell. Sorry to have kept you waiting’.
Avoid tunnel vision
Patients are likely to have preconceptions as to what is wrong, or another doctor’s diagnosis might be reported to you prior to the consultation. Do not feel obliged to accept any of these – keep an open mind and use your knowledge and experience to come to an appropriate diagnosis and assist the patient.
Many complaints and claims arise from a failure to check for relatively rare but serious diagnoses, because once a doctor has an idea of what is happening, there is a tendency to look only for symptoms and signs to confirm that belief.
Medical records
In unscheduled care cases, it is crucial that medical records are as comprehensive as possible. While this does take time when you’re already busy, if something goes wrong and you attract a clinical negligence claim or complaint, your records will form an important part of your defence and will be looked over by the regulator or legal team. I have reviewed several cases where GPs have said they examined a patient at home but did not record it, only to regret it later.
When you need help, ask for it
GPs may feel that they should be able to cope with the complex or unclear presentations and may not want to bother the busy hospital doctors – memories of their sleepless house jobs still vivid – but it is important that they treat each patient properly and efficiently. GPs must be prepared to ask other health professionals for help, when required.
Reflect on consultations
Before ending the consultation, take a step back and look at it objectively. Are you happy with the advice you provided and your note-keeping? Should you perform some extra checks? Has the patient fully understood what you have told them? Are you and the patient clear on the agreed follow-up plan?
If, on reflection, you decide that there is nothing better that you could have done during the consultation, you will sleep better after your shift. If not, you still have the opportunity to improve on the consultation.
In summary, working in any unscheduled care environment can be challenging, busy and potentially high-risk. However, as long as you are prepared for this, it can be satisfying change from daytime general practice.
- Dr Daniel Kremer is a GP and medicolegal adviser at Medical Protection
