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Medical Uncertainty: Supervision in General Practice - Dr Mark Burgin

11/03/21. Dr. Mark Burgin BM BCh (oxon) MRCGP discusses how the range of opinion around supervision of clinical staff by GPs can change the outcome of a CN case.

Supervision is an increasingly important role in general practice as tasks are delegated to a larger primary care team. Although some of the team are professionals and have their own insurance others have no formal training or are acting outside their area. The recent case about a receptionist giving (incorrect) about waiting times is an example of the former. Nurses seeing minor illness is an example of the latter and to a clinical negligence lawyer more significant. A general nurse who sees children with symptoms of minor illness cannot act safely on their own.

The general nurse training may include some time on a children’s ward, but their experience and training is based upon adult disease. However much continuing professional development and training courses they attend they cannot achieve the same performance as a paediatric nurse. Few nurses are dually trained in general and paediatric nursing and those that are say that it is difficult to keep up with two fields at the same time. Few professionals will admit that they do not sufficient training to do their role and it may be necessary for the court to make this determination.

In the nurse seeing children example above there is another complication, even a paediatric nurse does not have all the skills required to be a GP. Paediatric nurses a long and complex training that allows them to provide high level nursing cares to ill and disabled children. No GP would suggest that they could do a paediatric nursing job, particularly as HCA have largely taken over the easy tasks. It is not just nurses that find it difficult to recognise and work within the limits of their competence. A GP out of practice for 2 years is considered not to be able to safely assess children and must have further training.

Individual Professional Responsibility

Some experts are of the opinion that any professional working in primary care is responsible for ensuring that they are competent. They must make special arrangements to have an educational supervisor and additional support if they have areas of weakness. This belief is based upon the guidance issued by professional regulators such as the HCPC, GMC and the NMC. The advantage of this belief is that a negligent professional cannot blame the system for their failures. Removing a way out can simplify a case and prevent cases from falling between two defendants.

All professionals working in primary care have their own insurance which provides the clinical negligence lawyer with an indemnifier if blame is proven. It is far simpler to issue against a single professional than a group of practitioners. Unfortunately claims for missed diagnosis commonly involve several practitioners of different professional groups that may require several separate breach reports. Any advantage from preventing professionals to share their blame with their supervisor is quickly lost if there is a contribution from more than one professional.

These arguments are weaker when considering breaches by ancillary staff such as receptionists, secretaries and even health care assistants (HCA). Where there are written guidelines and the staff have not followed those guidelines then proving breach is straightforward. As they will have a contract of employment the employer will have insurance. There was some discomfort with the idea that a receptionist has a duty of care when advising waiting times but the court found for the claimant. These experts will argue that the matter is closed, whether supervised or not each person working in the NHS will have their actions considered in isolation.

Safe System of Supervision

Other experts are of the opinion that there are situations where the professional has done everything they can. They have reached the limits of the competence and have asked for assistance from the supervising GP and have been given an inferior substitute. The supervisor may have not seen the patient or not recognised a pattern of illness. They rarely write anything in the records and typically agree with the professional’s diagnosis even if obviously wrong. These experts are concerned that the professional was not supported and the supervisor will avoid their responsibilities.

Letting another person take the blame for one’s own errors feels unfair and the reasons given ‘I was too busy’ ‘the professional is good at their job’ are insufficient. It seems wrong for a GP to be able to delegate responsibility without providing any support. One reason given for this situation is that GPs are not naturally team workers and struggle to deal with interruptions. Those who choose a life of professional isolation may not have the skills or the interest in people management. This observation may be true but is not an excuse, GPs are highly intelligent adaptable people and should be able to create a safe system of supervision.

These experts then do further and point out that supervision is built into all the various models of primary care. If GPs are unable to create a safe system then the regulators will have to step in and impose one for them. They argue having staff is a privilege and there is a corresponding responsibility to supervise the staff that the GP has. The alternative is already happening where GPs lose their self employed status and have their duties written into a contract. These experts point out that failing to create safe systems of supervision is a breach in the duty of care.

The Pragmatic Approach

The titles for the jobs in primary care are so varied and ambiguous there are some practitioners who do not have a responsible body. Others such as independent nursing prescriber or physician’s assistant are an umbrella terms for many differently skilled professionals. The expert has the choice of saying that there is a reasonable system of supervision that would apply to everyone or considering the individual skills of the professional. In the latter the expert would consider written and oral protocols that were in place and the training logs and CV of the professional. An appropriate level of supervision for that individual would be proposed.

If the professional and practice chose not to make this evidence available, then a one-size-fits-all standard of reasonable supervision could be used. Any attempts to provide limited evidence would be challenged by application to the court for an adverse inference to be drawn for the failure to provide all the material evidence. As there will in many case already be an application for adverse inference for the GP’s failure to write contemporaneous records when consulted it would not require much additional for the solicitors.

The solicitor may feel that they need to find an expert on safe systems of supervision, but the reality is less complex. The judge does not need an expert to tell them that if the practitioner does not know who to ask, they are afraid of asking or no one ever asks then it is not safe. Even where there is a clear system of supervision if the record keeping is poor it is not likely to be safe. The expert required in these cases is one that can find the evidence for a system of supervision in the medical records. The broad-brush type of expert is not as suited to this sort of work as the attention to details expert.

Conclusions

It is not uncommon for a highly thorough and detailed assessment by a less experienced professional is followed by ‘d/w Dr KS continue’. This coded entry means discussed with the GP (Dr KS) and the doctor said that the management plan was correct. The professional has reached the limits of their competence and correctly asked their supervisor to assess the patient. The supervisor has failed to see the patient, failed to listen to the symptoms properly and failed record their advice. The symptoms are often a classic description of a disease that the professional did not consider.

The outcome is often that the case fails against the professional because they made a simple mistake and did their best to assess the patient. The letter of claim did not mention the supervising doctor (Dr KS) and the issue of supervision is not considered. The claimant does not recover any damages despite having been negligently misdiagnosed, the professional has suffered stress despite having done a good job and the supervisor is never involved. The lessons are not learned so the mistakes will be repeated.

This article is designed to stimulate discussion about an issue where there is medical uncertainty. Although the reasoning is grounded in ethics the article attempts to identify a range of opinion and then the author’s own opinion. For experts it can provide source material for their reports, for lawyers it may help win more cases. For those who teach ethics it is a way of making the subject less abstract and help professionals understand the importance of good systems. The point of a range of opinion is that the reader should find themselves disagreeing with much of the thinking.

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

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

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