Dealing with Covid related complaints in general practice

Caroline Fryar, Medical Defence Union (MDU) head of advisory services, looks at how the pandemic has shaped patient complaints and offers advice on how to protect your practice

As we approach the anniversary of the first confirmed coronavirus case in the UK, it’s become clear that the pandemic has magnified existing challenges in general practice and presented many new ones.  

Most people have been understanding about the constraints and compromises forced on practices by the health crisis. However, patients and their representatives have continued to make complaints against MDU members. While case numbers have been lower than in recent years we have still opened well over 3,000 complaint and adverse incident case files from the start of the first lockdown to the end of 2020.

During this period of heightened anxiety, some complaints are perhaps inevitable. However, it can help to anticipate likely problems in order to pre-empt them. This article looks at two issues that featured prominently in our complaint files during 2020 and provides some advice for practice teams on avoiding common pitfalls.

Remote consultations

In an MDU survey of GP members at the end of last year, 90% of respondents felt that working practices had significantly changed since the beginning of the pandemic with 97% increasing their use of telephone consultations and 75% adopting video consultations in their practice.

Remote consultations and triage are necessary in order to prevent the risk of infection and also offer greater convenience and flexibility. However, there are also limitations, such as the difficulties of communicating effectively and making a clinical assessment, which heighten the risk of a missed diagnosis.

These allegations are already starting to feature in the MDU’s Covid complaint files. These included cases in which there were alleged delays in diagnosing serious conditions such as bowel cancer, septic arthritis or stroke during remote consultations, which were later picked up during a face-to-face consultation and examination. 

Advice to protect against complaints:

• Make sure staff are familiar with the technology for all aspects of remote consultation.
• Staff responsible for telephone triage should talk to the patient about the process for arranging a remote consultation, and be trained to recognise red flags which may require an urgent face-to-face appointment.
• Assess the suitability of an online consultation, particularly if you don’t have access to records. Are there special considerations such as the patient’s age, ability to use technology or emotional state? Did the triage process reveal any red flags?
• Ensure the patient has privacy (unless they need support from a carer or family member) and can see/hear you clearly.
• Effective communication techniques during remote consultations include looking at the camera to make eye contact with the patient rather than your screen, introducing yourself, checking non-verbal cues where possible and repeating back what the patient has said to confirm you have understood their history and concerns.
• Have a low threshold for asking the patient to attend a face-to-face consultation where this is possible, for example if a patient has already consulted about symptoms that have not resolved.
• Only consider a remote prescription if you have enough knowledge of the patient and medication’s suitability.  
• At the end of the consultation, ask the patient to explain back their understanding of your treatment plan, next steps and safety netting advice such as what to do if their condition deteriorates.
• Arrange a follow-up appointment if required within a suitable timescale.
• Keep contemporaneous notes of consultations. Recordings (made with patient consent) should be added to the clinical record.
• Reflect on strengths and weaknesses of remote consultations. Discuss your experiences with your colleagues so that you can learn from each other.

Delayed referrals

The growing waiting lists caused by Covid pressures on NHS hospitals are outside the control of GPs but unfortunately as gate keepers, GPs may face criticism about delays. For example, delays in investigations for suspected breast or prostate cancer referrals. It can help to manage patient expectations and ensure you take reasonable steps to prevent patients coming to harm when making a referral. 

Advice to protect against complaints:

• Inform patients if there are delays for a particular service when you obtain agreement for a referral. Discuss alternatives with the patient.
• Ensure the patient understands whether the referral is urgent or routine and the timescale you expect for an appointment. Ask them to get in touch if they do not hear anything by that time.
• Provide safety netting advice so patients know what to do if their symptoms deteriorate before their referral is actioned.
• Make the urgency of the referral clear to hospital colleagues. For urgent referrals, highlight the relevant clinical detail to avoid this being relabelled as a routine referral if triage is carried out. In all cases, provide all relevant information in your referral including the patient’s history, medication, allergies, examination findings and details of any investigations.
• Report any deterioration or new symptoms to the department/specialist and inform them about any updated investigation results. Discuss the patient’s condition with relevant specialist if you believe further care can be offered in the interim.
• Consider implementing a system for referred patients to be reviewed where there is a long waiting time.
• You have a responsibility to raise concerns if you think that patient safety is or may be seriously compromised.  Discuss any specific concerns with your local medical committee without disclosing the patient’s identity. If you are experiencing difficulties, it is likely that other practices in the area are as well and a joint approach may be more effective.

Ultimately, the key to avoiding complaints during the pandemic is effective communication. Clear communication with patients about what to expect from the practice such as appointment availability, remote consultations and triage, and the importance of mask-wearing and social distancing when attending the practice in person can help avoid misunderstandings.

If you do receive a complaint, it is important to investigate it in the usual way, notifying the complainant if there are likely to be delays caused by the pandemic. Showing someone that their concerns are being taken seriously will increase your chances of resolving a complaint successfully. 

If you need help responding to a complaint or believe it has the potential to become a GMC investigation, seek prompt advice from your medical defence organisation.

Caroline Fryar is head of advisory services at the Medical Defence Union