Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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GP service "exceptional" during pandemic
- Maureen Baker, Martin Marshall (7 July 2009)
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GMC guidance on Good Medical Practice (2006) : application in circumstances of pandemic life-threatening infection
- Ian A Zealley (3 August 2009)
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Maureen Baker, RCGP Honorary Secretary RCGP, 14 Princes Gate SW7 1PU, Martin Marshall
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Establishing a system of “flu leads” has been an integral part of our planning and preparations for a pandemic – but it was never the intention that one person would be left to deal with all cases of flu in their particular area. Such an arrangement would be highly impractical, especially during periods of intense flu-related activity where GPs will need to see flu patients (generally those with flu-related complications) at home. The practice flu lead should be the person nominated to take forward the practical aspects of planning, normally in conjunction with the practice manager. This should be the person who also liaises with the Primary Care Organisation and other practices and who attends any flu meetings on behalf of the practice. As we have set out in the guidance documents, different working patterns will need to be accommodated by relinquishing more routine or non -urgent work. Home visiting will almost certainly need to be shared across a number of doctors in the practice as there is likely to be more demand than would normally be the case, even for non-flu patients. As hospitals come under pressure, some people who would normally be admitted to hospital will need to be treated at home and sharing the visits is a much more practical way of allowing for off-duty and accounting for GPs who become ill We must remember that GPs and primary care teams are as at much risk as anyone else of catching the disease and so practices should be considering whether any members of their healthcare teams fall into ‘high- risk’ categories for swine flu, for example, pregnant women or people with asthma or diabetes. If so, it is both practically and ethically reasonable for practices to direct them to non-flu work wherever possible. Despite the difficult circumstances, we must point out that the response has been excellent. The evidence shows that GPs and practices have put considerable effort into their planning and that they are mounting a magnificent response to the challenges of dealing with this outbreak. The response to the public health aspects in the containment phase was tremendous and recognised as such by colleagues in the Health Protection Agency. GPs in areas of significant outbreaks have responded by dealing with many more patients than normal, either by telephone or face to face consultations and they have also been volunteering to cover out of hours services – where there has been intense pressure – in addition to the extra work they are providing in their practices. Based on the efforts so far, the British public can rely on exceptional service from GPs and practices throughout the period of this outbreak. Dr Maureen Baker Honorary Secretary and Pandemic Planning Lead, Royal College of General Practitioners Professor Martin Marshall, Chair, Ethics Committee, Royal College of General Practitioners Competing interests: Dr Maureen Baker is RCGP Pandemic Planning Lead |
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Ian A Zealley, Consultant Radiologist Ninewells Hospital, Dundee, DD1 9SY
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Dear Dr Godlee, Proposal: an “Open letter” to the GMC regarding their guidance on Good Medical Practice (2006) : application in circumstances of pandemic life-threatening infection I would be most grateful if you would consider publishing the letter appended below thereby turning it into an “open letter” to stimulate debate. Recently many doctors, especially those with young children, will have given some thought to how they might behave if the current outbreak of swine flu transforms into a more virulent epidemic. In any event it is only a matter of time before this or some other infection leads to a serious pandemic carrying a heavy death toll. I believe that in their current form the “Duties of a Doctor” as prescribed by the GMC are unworkably idealistic because they place a duty on doctors to attend to patients whose condition threatens the health of the doctor even where there is no prospect of benefit for the patient. The rapid responses to Daniel Sokol’s article in January 1 addressed this topic but the current swine flu outbreak will have clarified thoughts somewhat. Daniel’s more recent article 2 also addressed these issues in the specific context of General Practice. There is a debate to be had and it is an important one. The profession would benefit if the debate were to be held between doctors in the first instance. It would be very interesting to determine the current views of the profession at large through the medium of the letter pages in your journal. With many thanks for your consideration, Yours sincerely, Dr Ian Zealley 1. Sokol DK. ”When can doctors stay away?” BMJ 2009;338:b165 2. Sokol DK. ”Who want to be the flu doctor?” BMJ 2009;338:b2567 OPEN LETTER TO THE TO THE GMC: Dear Professor Rubin, GMC guidance on Good Medical Practice (2006) : application in circumstances of pandemic life-threatening infection The current swine flu outbreak has stimulated thoughts of how doctors might behave in the scenario of a highly infective, virulent, life- threatening pandemic. Naturally doctors will turn to the GMC as their statutory overseeing body for guidance. However I find that in its current form paragraph 10. of the GMC guidance on Good Medical Practice (2006) presents me with a dilemma which I hope you can resolve. From the guidance; 10. All patients are entitled to care and treatment to meet their clinical needs. You must not refuse to treat a patient because their medical condition may put you at risk. If a patient poses a risk to your health or safety, you should take all available steps to minimise the risk before providing treatment or making suitable alternative arrangements for treatment. Although the document states that its precepts are for “…guidance, not a statutory code…” the rubric makes it clear that the term “you must” classifies this statement as an “overriding duty or principle”. The wording of this paragraph must surely be interpreted as meaning that this is the type of principle regarding which “…failure to follow…will put your registration at risk.” In the context of a highly infective, virulent, life-threatening pandemic this statement appears to me to be excessively idealised and unrealistic. Specifically the statement does not appear to consider the possibility that circumstances may arise where “…all available steps to minimise the risk (to the doctor)…” may be insufficient while at the same time “…suitable alternative arrangements for treatment…” do not exist. Both of these conditions may apply, and are indeed highly likely, in circumstances of highly infective, virulent, life-threatening pandemic infection. In such circumstances it is also very likely that treatment itself would be ineffective. In February of this year the GMC issued revised guidance relating to conditions of pandemic influenza. The revised guidance adds a rider to paragraph 10 which includes the following statement; In a pandemic, many doctors will have legitimate concerns about the risks of infection they face, or the additional risks to which they may expose their family, particularly if family members are identified as being in an ‘at-risk’ group. At the same time, the public has a legitimate expectation of receiving medical advice and help from the profession during a pandemic. The balance between protecting individual doctors and their families from harm, and ensuring patients are not put at unnecessary risk, is best addressed at local level, taking into account the principle that those who place themselves at additional risk should be supported in doing so and the risks and burdens minimized as far as possible. This rider does two things. It indicates that the requirement that doctors should not refuse to treat patients when their medical condition may put the doctor at risk has been considered, on reflection, to be inappropriate under certain circumstances. However at the same time it fails to provide a clear position and devolves this important issue to “a local level”. The GMC is a statutory regulatory body and has a level of authority supported by law. I believe it should stand up a little taller. Such an important precept is precisely the sort of issue which should not be devolved. Guidance must be based on realistic assumptions if it is to be relevant and thereby acquire natural authority. Guidance based on idealised scenarios, and which requires revision when unanticipated scenarios emerge, does not inspire confidence. I propose that the GMC should have realistic expectations of the profession they regulate. This does not mean that I expect the GMC to advocate reduced standards of professional conduct. It means instead that this particular standard should be couched in terms which are at the same time upstanding but do not require doctors to behave in a manner which would be futile for them, their dependents and, ultimately, the public at large. I suggest that the GMC consider the following re-wording of paragraph 10; 10. All patients are entitled to care and treatment to meet their clinical needs. You must not refuse to treat a patient because their medical condition may put you at risk. If a patient poses a risk to your health or safety you should take all available steps to minimise the risk before providing treatment. If these steps are insufficient you should make the best available alternative arrangements for treatment Many thanks for considering this letter and proposal. Yours sincerely, Dr Ian A Zealley Competing interests: None declared |
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