Dr Gerard Panting looks at some medico-legal aspects of endoscopy and minor surgery services and nurse-run clinics
Q I have been asked to take an extended role in our PCT by providing gastroscopy services. I am not sure about the medico-legal implications of accepting this role.
A Before undertaking any procedure, you must have the requisite expertise as well as all the necessary facilities and assistance to complete it to a reasonable standard and to deal with any reasonably foreseeable complications that may occur.
In the event of a complaint or claim, your defence will depend upon being able to demonstrate that your management was in keeping with accepted medical practice. So before you start providing endoscopy services, it would be wise to discuss the proposal with a local gastroenterologist and perhaps undertake a few gastroscopies under his or her supervision, particularly if there has been a gap in your own practice.
This also provides an opportunity to discuss the facilities that you have available and satisfy yourself that they are adequate, and also to establish a process for onward referral of patients whose history or gastroscopy findings warrant such action.
Keeping up to date is another issue you need to consider, especially with annual appraisal and revalidation in mind.
The bottom line is that when providing services of this sort, you have to be confident that you can complete competently anything you take on.
If something goes wrong, you will be judged by the standard of someone holding themselves out to be able to gastroscope patients. Your peers in this sense will be other doctors carrying out the same procedure who in the main will be consultant gastroenterologists. There is no lower standard for GPs with a special interest.
Q We provide a variety of surgical procedures for our patients. Until now we have not asked patients to sign consent forms ¿ should we do so?
A Consent forms attract considerably more attention than they deserve. They are at best just one piece of evidence that valid consent has been obtained ¿ but the presence of a signed consent form is never the end of the argument.
There are three issues to consider in any discussion about the validity of a patientÍs consent. First, was the patient competent? We assume, unless there is good evidence to the contrary, that adult patients are competent, but if there is any doubt over competence it should be formally assessed.
Second, did the patient have the necessary information to come to an informed decision? Information is key in the consent process. Before being asked for their consent, patients should be aware of the nature and purpose of the treatment or procedure, the expected outcome, potential side-effects and complications, available alternatives - including doing nothing - and any other material information.
All their questions should be answered honestly and fully. This dialogue will come under intense scrutiny if there is any question over the validity of consent.
Third, was consent given voluntarily? Consent given under coercion is no consent at all. Coercion in medical practice is not about holding patients down (although that would certainly qualify), but is about inappropriate persuasion or failing to provide patients with sufficient time to mull over their options.
If there is any doubt as to whether or not valid consent was obtained, the exchange between doctor and patient will be examined in detail; a consent form plays a relatively minor role in the proceedings.
Q Our practice wants to employ a nurse to undertake a variety of tasks including an open access clinic for such conditions as diabetes, asthma and hypertension. Are there any medico-legal issues we should be aware of?
A Your proposal is certainly in line with Government policy to enhance the role of nurses and other non-medical staff in the delivery of clinical care.
The main issue here is ensuring that the nurse concerned is competent to do what is being asked of him or her. This comes down to selection, training and agreeing clear protocols setting out how patients in each category should be managed, the advice and treatment the nurse can provide and when the patient should be referred back for review by the GP.
As in the first question, it all boils down to ensuring that the patient receives a reasonable standard of care - the courts do not accept a two-tier standard.
There is also the question of indemnity. As the nurse is going to make clinical judgements based on her own findings, she should have indemnity of her own, provided through the Medical Protection Society or another reliable source.