Medico-legal - Perils of cutting healthcare costs

The introduction of commissioning consortia present GPs with new challenges. By Dr Nick Clements

The care of their patients must always remain GPs’ first concern (Photograph: SPL)
The care of their patients must always remain GPs’ first concern (Photograph: SPL)

Most doctors have experienced potential conflicts between rising patient expectations and finite resources. These will become increasingly frequent with increasing pressure to control costs. The introduction of commissioning groups will put GPs in the forefront of these changes, and give rise to new challenges for doctors in balancing their responsibilities.

Basic principles
Doctors are not responsible for the overall resourcing of the NHS, though they are often responsible for allocating some of those resources, either in general terms or to groups of patients or individuals.

Doctors are accountable for their decisions, and must do their best to achieve a reasonable balance between their responsibilities. When resources are limited, they must still do their best, and be prepared to justify their decisions and demonstrate their reasoning.

Doctors' responsibilities
As registered medical practitioners

The GMC expects doctors to make the care of patients their first concern (Good Medical Practice, para 1), and to make good use of available resources.

The GMC does not impose an absolute obligation on doctors in terms of resources - only to do the best they can with the resources available.

If resources are so limited as to endanger patients, the GMC expects doctors to take further action, and either take steps to put matters right, or draw their concerns to their employer or contracting body's attention.

As a manager
The GMC guidance Management for Doctors acknowledges that managerial responsibilities can include difficult decisions about resources. Decisions about resources should be based on all the available evidence, taking into account government and NHS priorities.

Where managerial duties conflict with primary professional duties, then doctors should declare the conflict and seek advice from colleagues, and raise their concerns with senior management and external professional bodies.

As an employer
Doctors must comply with all relevant employment law and act in good faith to their employees, but hard decisions can be made if necessary. Wise use of limited resources can mean reviewing priorities and working practices, including staffing levels.

Make sure all the issues are considered, and records of the process kept. Seeking expert employment law advice is wise.

Employees cannot be asked to act illegally or unlawfully, and it would be unwise for a doctor acting as employer to insist that another doctor act in breach of GMC guidance.

As an employee
Employees must act in good faith, carry out their duties to a reasonable standard, and follow reasonable instructions from their employer. This would not include instructions to act illegally, nor should doctors act in breach of GMC obligations.

Employees are not responsible for organisational resources - only for making the best use of them and ensuring any patient safety concerns are flagged up.

The challenge of commissioning
A significant new challenge stems from the proposed abolition of PCTs and setting up GP consortia which will take on the responsibility for commissioning decisions.

All practices will belong to a local consortium, and some GPs will be working within the consortium, and participating in commissioning decisions.

Hard choices will have to made, and these are likely to be reinforced by the recent change in the role of NICE.

Individual doctors remain responsible for clinical decisions about their patients, within the framework imposed by the consortium. The basic principles will remain unchanged.

Concerns that resource issues are seriously compromising patient safety will need to be drawn to the attention of the consortium.

There must be clear separation between commissioning decisions and individual clinical/provider decisions.

Individual doctors are not responsible for commissioning decisions, simply by being a member of a particular consortium: their role is simply to do the best they can, and act reasonably in all circumstances.

GPs with dual roles
The position of practising GPs who are also involved in the commissioning process, is essentially the same though challenging to explain to patients and local communities.

In essence, GPs in this position must ensure there is clear water between their two roles:

  • In the commissioning process - they will need to justify their commissioning decisions and demonstrate their reasoning.

This must be based on an assessment of local needs, together with any national guidelines, requirements, and so on.

  • In providing care and services in their own practices and to patients - for which they will continue to have responsibility, through the usual routes, such as the NHS complaints process.

Where individual patients raise concerns they must be guided in the right direction - complaints, concerns or challenges to the commissioning process must be directed to the consortium and not the practice.

Case study

Mrs A is concerned about her father, Mr B, a resident in a local nursing home. His medication has recently been altered, and she believes the previous drug suited him better. She is also upset that local rehabilitation services to nursing homes have been withdrawn. Mrs A believes these decisions have been made on cost grounds, rather than on clinical need, and complains to the practice.

The decision about choice of drug was made by Dr X, on clinical grounds. This should be dealt with through the NHS complaints procedure in the usual way.

The withdrawal of the rehabilitation services was decided by the local consortium to which the practice belongs. Even though Dr X works for the consortium one day a week, and participates in the commissioning decisions, it would not be appropriate for the practice to deal with this aspect of the complaint, which needs to be passed to the consortium.

Explaining this to Mrs A will be challenging.

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