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Short Notes on Clinical Guidelines 2018 - Dr Mark Burgin

Dr Mark Burgin BM BCh (oxon) MRCGP considers the elements that should be included in a primer for clinical negligence cases involving clinical guidelines.

Clinical guidelines attempt to provide a ‘one size fits all’ solution for a specific medical problem so that the average quality of clinical management increases.

There are significant problems with all aspects of guideline writing as there are many causes, ineffective treatments, biased advice and patient preference.

Systems analysis theory states that the maximum effectiveness of any system is 70% but guidelines typically fall well below this standard.

Few guidelines are subject to research to determine how effective current practice is and whether adopting the guidelines cause an improvement in patient health.

Where a doctor has followed a guideline they will be in breach if they have not explained the limitations of guidelines when consenting a patient.

Individual care

Guidelines may be used by health authorities to restrict non guideline care against the recommendations of the guideline writers themselves see NICE.

“When exercising their judgement, health professionals are expected to take this guidance fully into account, alongside the individual needs, preferences and values of their patients.”

Working with a patient to find an effective treatment after the usual treatments have proven ineffective involves considering other models of the illness.

This can lead to a treatment that is partially or even completely effective but the patient is then refused the treatment by another doctor as it does not follow the guidelines.

This failure to respond to the patient’s individual needs is in breach of several aspects of GMC good medical practice e.g. part 2.

Rationing Popular Treatments

Many treatments are restricted because they are not considered cost effective, they are illegal or have lack of proof of their effectiveness.

NHS funding was lower in the past when some of these treatments were available so it is difficult to explain why they are now restricted.

Blanket bans have been challenged in the courts, so the treatments are considered on a case by case basis based on individual applications.

Patients who have the money can travel to other countries where the treatment is available or go private or obtain the treatment illegally.

Where NHS policy is conflict with a patient’s best interests the doctor may be in breach if they fail to make reasonable efforts when making applications for special treatments GMC GMP 71.

Restricted Access to Advances

The average delay between an advance being discovered and general application in the UK health system is said to be 17 years although significantly less in other countries.

This slowness has advantages as the delay allows safety studies, the price will often fall and access is restricted to a few specialists who can develop experience.

There are some disadvantages as novel applications are not studied, the UK lags behind other countries and patients miss the window of opportunity to prevent complications.

The government has been forced to bypass the official routes of accessing advances for instance the Cancer fund or Cannabis for childhood epilepsy.

The UK is reluctant to allow GPs have access to the latest advances but GPs will be in breach if they do not discuss the advances and the patient’s options when consenting a patient. Montgomery.

Research Opportunities

Although rare diseases individually occur rarely together they affect many patients and in the most part rare diseases do not have effective treatments.

There is concern that patients with rare diseases could be exploited offering hope of a possible cure that will not arrive and instead provide inhuman or degrading treatment.

The reality is that most sufferers benefit from the knowledge of their disease has been increased by participating in research and they do not have any expectation of being cured.

The doctor must consider the best interests of the patient and where there is no hope of cure the doctor should recognise that the patient is at risk of exploring other options

There is a duty upon the doctor under the Human Rights Act 1998 art 3 to give advice to avoid exploitation e.g. by explain how to apply for an official research trial or doing a home DNA test.

Conclusions

Doctors can be in breach of the standard of care of a reasonable doctor if they follow guidelines without taking into account the given circumstances.

These include failing to address individual patient needs, failing to document their patient’s extraordinary needs for rationed treatments and failing to provide the best available care.

The doctor has a duty to help the patient be as involved with their disease as they wish to, and this includes research whether to have new investigations or new treatments.

A doctor cannot simply say ‘I was following orders’ as a defence when the guidance was not effective and the patient was suffering.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

NICE “When exercising their judgement, health professionals are expected to take this guidance fully into account, alongside the individual needs, preferences and values of their patients.”

Human Rights Act 1998 art 3. “No one shall be subjected to torture or to inhuman or degrading treatment or punishment”.

Montgomery v Lanarkshire Health Board [2015] UKSC 11

GMC good medical practice (2013). 2 Good doctors work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability.

GMC good medical practice (2013). 71 You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. 22 You must make sure that any documents you write or sign are not false or misleading. a You must take reasonable steps to check the information is correct. b You must not deliberately leave out relevant information.

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