Practice dilemma - Latecomer at practice meetings

One of the partners persistently arrives late to practice meetings, and as a consequence repeatedly misses the review of referral letters. How would you address this?

A GP's response
Dr Raj Thakkar is a GP partner in Wooburn Green, Buckinghamshire

Partnership issues are often complicated and should always be dealt with sensitively, fairly and by considering all of the issues that may be involved.

Reflecting on why he may be running late is the first step. Does he run late for other meetings or his surgeries? Does the meeting start too early? Has he always run late or has there been a change in behaviour? If so, why?

Perhaps there has been a change in his home circumstances. Perhaps he is fearful of the referral review process and is 'silently sabotaging' the meeting.

Once you have reflected on these issues, consider what you want to achieve from a meeting with him. The approach should not be threatening and the meeting should be held in private.

A general question about how things are going is an appropriate start. You may pick up that things are not good at home or that there are other stresses, perhaps in the practice, that require support. If this is the case, are his stresses affecting his clinical judgment?

Asking what he thinks about the referral review process may be a direct way to approach the issue, or perhaps turning the situation on its head by suggesting that you find it threatening, and asking what he thinks.

He may open up to what his concerns and anxieties are. If he finds the meetings threatening, consider why? Can he suggest another way that he would find more acceptable? Can you negotiate a system acceptable to all?

The message here is to consider all of the issues before jumping to conclusions, be supportive of your work colleagues and negotiate appropriately.

Photograph: Getty images

A medico-legal opinion
Dr Lyn Griffiths is a medico-legal adviser, Medical Protection Society

In order to maintain a good relationship with your colleague and to maximise any likelihood of achieving a change in his conduct, it is preferable that you try to avoid conflict and raise this issue in a facilitative manner.

It may be helpful to emphasise the benefits to patient care of sharing information between partners and to advise him of your views on the value of audit and peer review.

Should this approach fail to have the effect you seek then you may need to remind your partner of his obligation to keep up-to-date and to maintain and improve his performance.

In accordance with guidance published by the GMC in its booklet Good Medical Practice, doctors in the primary healthcare team need to communicate effectively with colleagues and participate in regular review of the standard and performance of that team.

Doctors should reflect regularly on the standard of their practice and involve themselves in any process that monitors quality assurance and identifies any need for improvement.

They should respond constructively to the outcome of audit and contribute to procedures designed to enhance patient care.

Late attendance at practice meetings to review referral letters is unlikely to be an isolated feature of this GP's performance. There may be other time-management problems that affect patient care more directly.

You may therefore feel it helpful to ascertain if there are any other areas of poor time keeping that need to be addressed before you meet with your partner to discuss his late arrival at practice meetings.

A GP trainer's response
Dr Chris Elfes is a GP trainer and nMRCGP assessor in Swanage, Dorset

This is a problem that needs to be handled well by someone with good leadership skills in order to bring about the desired outcome without any one partner 'losing face' and while preserving an effective team that can move on in partnership.

More information is needed about the problem, and an appropriate person in the practice needs to be delegated to lead on this.

Is the problem part of a wider pattern that might cause concern? In particular is there any concern about patient safety in other aspects of this partner's work? Problems like this can have a long list of potential causes, ranging from stresses at home, burnout or alcoholism to poor time keeping, personality clashes or perhaps a wider dysfunctional partnership team.

Assuming there is no other major concern then the delegated person (partner or practice manager) needs to informally approach this partner and explain politely that there is a problem that needs resolving, and outline honestly the concern that has been raised and the impact this has.

The delegated person needs an appropriate level of experience and a reasonable working relationship with this partner, and will need to use their good communication skills to sensitively explore for personal problems and firmly but fairly negotiate a way forward.

Assertiveness skills will be important and a plan of action needs to be drawn up and documented. Other steps might include a wider partnership meeting to discuss the problem objectively, with a non-critical chair facilitating the meeting to reach an agreed way forward.

It might be a simple matter of helping the partner to resolve personal difficulties in child care or changing the time of the practice meeting. The importance of the meeting and the way the discussion of referral letters is handled should be reviewed in case this has been the problem.

Once a plan of action has been agreed, a review date should be set and a responsible person appointed to ensure this is undertaken.

If a satisfactory outcome for all parties is achieved then a practice with an embedded learning culture could use the whole issue as a significant event and learn valuable lessons on how well the matter was handled and how to prevent similar partnership issues from arising.

Sadly, more serious problems may have arisen and outside help might then be needed for more expert conflict resolution or assessments of patient safety, but this will hopefully remain a rare situation.

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