Who wants to be the flu doctor?
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2567 (Published 29 June 2009) Cite this as: BMJ 2009;338:b2567
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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
Competing interests: No competing interests
GMC guidance on Good Medical Practice (2006) : application in circumstances of pandemic life-threatening infection
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
Competing interests: No competing interests