Q How can we be sure that an agreed guideline will stand up in court? When things go wrong, as in time they surely will, what would constitute a 'responsible body of medical opinion' in the context of guidelines?
A If a clinician's practice is consistent with a guideline that has been developed on the basis of the best available evidence, it is unlikely that a court will hold that the decisions were negligent.
This does assume that the search for evidence underpinning the guideline has been thorough and complete, that the recommendations are a reasonable interpretation of the evidence, and that the practitioner has considered the extent to which the guideline applies in the particular case.
However, following a guideline – even if it is sound – does not provide an absolute defence against a claim for negligence. On the other hand, decisions that do not accord with a guideline do not amount to proof of negligence.
The courts accept that evidence is not always available for every aspect of care, that where it is available it does not always speak 'with a clear voice', and that guidelines may not apply to a particular case. The courts expect doctors to use their professional judgment .
You should consider any relevant guideline when making decisions and record your reasons for departing from it in the patient's notes. For example, you may judge that the patient is unlikely to comply with the recommended treatment and that the outcome is likely to be better if you use another regimen that may not be as good, but with which the patient will comply.
If you are asked to defend your actions, this will show not only that you are aware of the relevant guideline(s) and considered them, but also that you exercised your clinical judgment and the reasons for your decision.
What is probably indefensible is ignoring a sound guideline for no clear reason. Exercising clinical judgment – clinical freedom – is not the freedom to do whatever one likes.
As far as a 'responsible body of medical opinion' is concerned, it is deliberately left open to the courts to take a view according to the circumstances and merits of the case. In the context of guidelines, this probably implies:
- Taking account of all available relevant evidence
- Interpreting the evidence using accepted statistical, epidemiological and clinical criteria
- Where scientific evidence is not available, an agreed approach based on sound observations of a group of practitioners with experience and expertise in the subject under consideration.
Q Guidelines for tetanus vaccination seem to have changed a great deal over recent years. We are a rural practice with much farm-related minor trauma. Are there agreed current guidelines, bearing in mind that many patients will have had full courses already?
A Current DoH guidance is that the primary course for those under 10 years of age should consist of three doses of vaccine, usually as DTP 0.5ml subcutaneously or intramuscularly, with 4 weeks between doses. For those over 10 years of age, adsorbed vaccine is recommended using the same regimen.
Those who have had a primary course at less than 10 years of age should have a booster dose at school entry or 3 years after the last dose. Those who have had a primary course at age 10 or more should have a reinforcing dose at the time they leave school or 10 years after the primary course, with a further booster 10 years later.
There is a lack of consensus about booster doses for a patient who has suffered trauma in circumstances where tetanus is a risk, e.g. a penetrating injury of the foot caused by a gardening implement.
Some believe that once immunity is established, it is established for life even if antibodies cannot be detected. Others, however, believe that the body requires further challenges to maintain useful antibody levels.
I am not aware of any evidence that a tetanus immunisation given before it was due, according to Government guidance, causes any harm, but it is wise to refrain from giving therapy unless there are good reasons to do so.
Finally, there are those who feel that heavy contamination deserves a more interventionist response than clean wounds, and others who believe that you are either immunised or you are not.
So, the response seems to depend less on scientific evidence than on whether you tend to conservative decisions or interventionist ones. For interest rather than guidance, my own practice as a GP was:
- Not to give a further dose if the wound was clean or lightly contaminated, if the patient had had a primary course and booster(s) at the appropriate times.
- To give a further dose if the last one was more than 5 years ago and the wound was moderately contaminated.
- To give a further dose, even if the last dose was less than 5 years ago, if the wound was heavily contaminated and particularly if the injury was abrasive and it was not possible to clean it thoroughly.
Q Do guidelines exist for the ease with which patients can get appointments in different situations? We are trying to re-jig our appointments system and find it hard to know what is a reasonable waiting time for a routine or soon appointment.
A 'Guidelines' in this situation are not the same as those based on randomised controlled trials or other standard epidemiological study designs. Waiting times are social policy matters, not scientific ones. I am not aware of national guidance on waits for GP appointments.
Principles for waiting times for appointments are that the patient should be seen:
- Immediately if the complaint is, or may be, serious.
- Within a time frame appropriate to the clinical circumstances (e.g. a wait of 2 weeks to see someone with dysuria is too long) or the social circumstances (e.g. if someone is complaining of heartburn and is due to go on holiday in a week, the appointment should, if possible, be given before he/she goes on holiday).
- Within a time frame that is broadly acceptable to patients.
A good way to establish objectives for your new appointments system is to ask a random sample of your patients for their views on the general issues, using robust but simple survey methods.
As far as clinical issues are concerned, members of the practice team should divide these into broad categories and decide a policy on each so that your receptionists can ask the right questions and offer an appropriate appointment.
In general, long waits are not helpful to either patients or the practice. If, every day, there are more requests for appointments than can be met, your new system should look at ways of reducing the demand so that it matches supply.
Not offering patients an appointment for 2 weeks unless the complaint is life-threatening may force some people to live with self-limiting conditions and put others off getting a consultation that would benefit them.
If you want your patients not to come to the surgery for certain conditions, consider a proper publicity campaign explaining when patients can benefit as much from helping themselves (and how they can do this), and the reasons why it is in everyone's interests that they don't take up the GP's time if they do not really need it. This approach is likely to be better received by patients, safer, and more effective than inflicting long waits haphazardly on many patients.