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kdiwavvou:
[logged]Exclusive: GPs warned over accepting Christmas gifts from patients
By Neil Durham, 16 December 2013
GPs should consider potential ethical dilemmas before accepting gifts from patients this Christmas, warns medical defence organisation MDDUS.
Patients giving GPs presents may seem harmless but could have implications for the treatment GPs provide or patients expect, it says.
MDDUS medical adviser Dr Barry Parker said: ‘In all probability, patient gifts may be a genuine expression of appreciation for the care or treatment they have received. Even so, the complexities of the doctor-patient relationship mean difficulties can occasionally arise if the doctor accepts a gift from their patient.
‘In some cases, it might be entirely appropriate to accept a small token of gratitude, but there are times when a gift can represent something more.
‘By accepting a gift, a doctor may feel that they are indebted to the patient, influencing their clinical judgement. This may impact on the doctor-patient relationship and make objective decision-making more difficult.
‘Ultimately, doctors should consider whether by accepting a gift, they are altering their relationship with the patient. Factors that may influence the decision include the size of the gift and whether the patient is vulnerable or may be trying to influence their care. It is also worth considering how acceptance of the gift may be perceived by the public.
‘If doctors have any of these concerns, then they should be prepared to refuse the offer of the gift,’ he added.
The GMC offers guidance in Good Medical Practice - Financial and commercial arrangements and conflicts of interest.
GMS contract regulations state that a register should be kept of gifts from patients or their relatives which have a value of £100 or more unless the gift is unconnected with the provision of services.[/logged]
kdiwavvou:
How NICE plans to reshape general practice
[logged]By Stephen Robinson, 24 May 2013
'I''m passionate that NICE's work should become much more relevant to GPs,' Professor David Haslam told the institute's annual conference this month.
The vow from the new NICE chairman and former GP is one of several changes to how NICE works that will affect primary care over the coming years. With GPs increasingly expected to practise what NICE prescribes, these changes will mould the evolution of general practice.
The institute, now recategorised as a non-departmental government body, has been given the task of replicating its evidence-based advice on healthcare for England's social care system and integrating the two systems, along with public health guidance.
Add in quality standards, value-based pricing, CCG performance targets and the QOF, and it is clear the recent exponential growth in published advice and recommendations is likely to continue.
This prediction may make GPs cringe: many already see the sheer quantity of NICE guidance for primary care as overwhelming.
Spearheading change
Professor Haslam, formerly chairman of the RCGP, was appointed in April to spearhead these changes. Speaking to GP at NICE's conference in Birmingham, he acknowledges that digesting the guidance must be made easier for busy GPs.
Professor Haslam believes technology is the answer. 'As far as NICE is concerned, I think the quality of our products is exceptional; the rigour they've gone through,' he says. 'But I'm also aware that in a brief consultation, it's vital that we work out a better way of integrating guidance with GP computer systems.
'Now, what that doesn't mean is a bunch of templates that you have to fill in. But it does mean real-time support for doctors at the time they are faced with the patient, where they can be linked with what best practice is at the time. We have to take on board the use of technology to address this, otherwise, there's too much information.'
The recent growth of NICE's public health advice raises the spectre of reams of extra guidelines for general practice to follow - unpalatable at a time of workload strain.
Professor Haslam says greater GP involvement in wider public health work is inevitable, but insists NICE will do its part to make sure the profession is not burdened with recommendations. 'GPs at the moment feel they are almost overwhelmed by the amount of work they are doing, so simply adding more tasks is not something many practices are going to welcome,' he says.
Delivering healthcare
'But I am aware we're at the beginning of a real change in the way healthcare is delivered. I think the boundaries between primary care, secondary care and public health are going to change really quite dramatically,' he says.
'The whole public health remit and where that fits into the world of local authorities, CCGs, and health and wellbeing boards, again, it's all to play for at the moment. I don't know how this is going to fit, but I don't want GPs to feel this is yet another thing to add to an already over-busy day. We have to work out a better way of getting this all joined up.'
His colleague, NICE deputy chief executive Professor Gillian Leng, also a former GP, says in future, NICE's health guidance for GPs will be far more integrated with other areas such as social care, on which NICE has been asked to provide advice.
'Hopefully, GPs will get a more integrated set of guidance, as GPs are crucial to integration. We are aiming to integrate our health and social care work to make it look more seamless,' she says. 'But it's about making sure it's framed in language that meets the requirements of GPs and the social care setting.'
Professor Leng says NICE's early work has uncovered medicines management in care homes as an example of an area that needs better ties between health and social care. Here, there is often confusion about who is responsible for prescribing.
'A lot seems to relate to the fact that people in care homes are on a large number of medicines,' she says. 'There's clearly an issue about reviewing what those individuals are taking, and reviewing whether these are administered appropriately.'
Social care
Designing social care for patients recovering from a stroke, for example, may not directly require input from GPs, but it is 'important they see the big picture', she says.
What all this means for everyday GP work is unclear and the profession cautiously awaits the first social care guidelines, due by early 2014.
Multimorbidity is one of the key challenges posed by the ageing population, and this formed a cornerstone of Professor Haslam's opening speech to the NICE conference.
In it, he explained: 'The spectacular demographic changes this country is facing ... inevitably means multimorbidity is the norm, and generalism becomes ever more important.'
Professor Haslam admits that NICE faces a challenge to accommodate this complexity in its guidance, but says this is essential if guidance is to become more meaningful to primary care. 'I've talked many times about patients with heart disease, kidney disease, arthritis, depression, where working out what is good for that individual is quite complex.
'You have to work out a way of not just adding guidelines and guidance together, because you end up with something that is almost certainly the wrong answer for an individual.
'But how we're going to come up with that answer, I don't know. I'm committed to doing it, because I know it's what GPs need from us and what patients need from us.'
Profile - Professor David Haslam
'I realised a long time ago,' says former GP Professor David Haslam, 'that having a meeting with a minister or a senior civil servant was exactly the same as holding a consultation at a practice.'
Professor Haslam believes his time in general practice was perfect preparation for his newest challenge as the chairman of NICE.
He believes there are clear parallels between dealing with patients and with politicians. 'You have to explore their ideas, concerns, expectations. In general practice, talking to someone where it really matters is the most remarkable training for a role like this.'
Professor Haslam was once a GP in Cambridgeshire, but now is perhaps best known for his roles as RCGP chairman in 2001-4, college president in 2006-9 and BMA president from 2011 to 2012.
He currently advises the government through his position on the National Quality Board, and is a visiting professor in primary healthcare at De Montfort University in Leicester. Author of 13 books, mainly on health, he was awarded the CBE in 2004 for services to medicine and healthcare.
In April, he took over the helm of NICE from Professor Sir Michael Rawlins, who has won acclaim for steering the institute for the 14 years since its inception in 1999. Professor Haslam says Sir Michael gave him 'a lot of advice' and was 'extremely supportive' during the handover. 'He'd been in the role as chairman for 14 years and I could not praise him more, he's done a remarkable job,' he says.
He describes his first six weeks in the role as 'fascinating' and says it is 'very interesting' that NICE appointed a former GP to the post. 'It's a measure of the centrality of primary care in so much of what's going on in healthcare delivery and policy,' he says.[/logged]
kdiwavvou:
Practice dilemma - When consultant opinions conflict
02 June 2011
The Dilemma - You see a 39-year-old woman with migraine that does not settle on conventional treatment.
She happens to have private medical insurance. On full examination, you notice that she has a subtle heart murmur and wonder whether she has a patent foramen ovale (PFO), thought to be associated with migraine. You arrange a neurological referral and organise for her to see a cardiologist. The cardiologist feels she should undergo PFO closure, whereas her neurologist is vehemently opposed, saying that neurologists do not believe such a procedure will resolve her migraines. The patient comes to you angry with the situation and confused about whether she should have the procedure. What should you do?
A GP's response
Dr Zara Aziz is a GP in Bristol
The dilemma here is that the patient has been given conflicting advice for the same problem but from two different perspectives. I would like her to know that PFO is present in about 25 per cent of the general population and is asymptomatic in most cases. The physiological mechanism of how the condition may be linked to migraine is not understood.
PFO can be closed using an endovascular procedure, as suggested by the cardiologist, but the evidence for this in the prevention of migraine remains inconclusive. The patient should be made aware of the uncertain efficacy of the procedure and the possibility of any complications that could arise from it.
There is a small incidence of serious adverse events caused by closure of PFO. I would like the patient to have access to written information about what the procedure would entail. NICE has recommended that patient selection for PFO closure to relieve migraine should be carried out jointly by a neurologist and a cardiologist. The procedure should only be carried out in specialist units and the results should be audited.
I would be interested to hear the neurologist's advice on managing her migraines through other means. The two specialists are not in agreement so it may be that a second opinion has to be sought from both specialties. The patient's best interests should be paramount and information should be presented to her clearly so that she can make an informed decision.
It is very likely she will need time to think and a follow-up consultation should be arranged to discuss any unresolved issues.
A medico-legal view
Jim Rodger is head of professional services with the UK-wide Medical and Dental Defence Union of Scotland (MDDUS)
You have a difficult situation with an irate patient and no wonder. The patient has a problem, for which she seeks help, and there may be an effective treatment. The matter here is one of informed consent.
The patient has been offered a surgical intervention and to consent to go ahead with that, she needs clear and understandable information on which to base her decision. You might try to find more information about the condition and its relationship to the migraine, an area which may be unfamiliar to most GPs.
At the same time, you might share this increased knowledge with the patient or point her in the direction of helpful reading material. She should be in a position to understand the difference in the consultants' opinions and why they might hold these views.
You could also agree to seek other opinions; because her private insurance will not agree to multiple opinions, this could be done at modest cost to her.
She might also be able to secure another opinion from within the NHS. The condition does not indicate great urgency and there would be time for you to gather more views.
You might write to each of the consultants to indicate that their disagreement has affected the patient's trust and seek some form of compromise, so that the patient can come to an informed decision about her treatment.
A patient's opinion
Jacqui Storer is an expert patient
The patient is, in part, the architect of the situation, in that she is seeking an alternative route to the conventional approach. The referrals sought have resulted in conflicting advice.
The patient must be assured that every possible avenue is being explored, with her well-being and opinions given full consideration. Her anger is justifiable because she feels vulnerable and not in control of her situation because she is receiving conflicting opinions, in addition to being unwell.
Dialogue with, and explanations from, both consultants about why their views conflict are needed. The patient also needs reassurance in the form of accepted facts and the reasoning behind the respective opinions. This may help to alleviate her anxiety, confusion and anger.
The patient is searching for a resolution of her condition in an unconventional way, so she must be made aware that this cannot be achieved without first considering the positives and negatives of the procedure. She needs to feel that she is in charge of her own health. Her dilemma must be resolved in a balanced and sensitive manner, and she should be given the opportunity for meaningful discussion.
The options need to be evaluated by all parties with evidence-based explanations, from which the patient will be able to come to a rational decision. Time must be allocated to enable her to feel involved in any judgments made on her behalf.
What is now needed is the provision of complete reassurance for the patient and the demonstration of respect for her opinions. Meaningful dialogue will help guide her to an acceptable outcome with compassion and dignity.
kdiwavvou:
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