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6 Perils of the twilight zone

There has been a significant rise in out-of-hours complaints and claims against GPs. Dr Rachel Birch and Dr Richard Stacey explore the risks of working in this environment, drawing on real cases


uring the last few years there has been a distinct rise in complaints and claims arising

from consultations in the out-of-hours (OOH) setting. Providing general practice care in the OOH setting carries both unique risks and vulnerabilities. This is the result of several factors

that can be summarised as follows: ■ ■ In most OOH consultations GPs

are dealing with patients who are completely unfamiliar to them, and it is recognised that such patients have a lower threshold for making a complaint or claim.

■■ A consulting GP in OOH will not have access to the patient’s complete GP records.

■■ The fact that a patient is calling OOH may reflect that they have a

heightened degree of concern about their symptoms and/or feel it needs dealt with as a matter of urgency.

■■ Patients may have an unrealistic expectation that they are entitled to a home visit and/or may be unhappy at having to travel to an OOH centre.

■■ Telephone triage has its own unique risks.

■■ While the vulnerabilities in the OOH setting differ to those in conventional general practice, the steps you can take to protect yourself are remarkably familiar.

Clearly communicate Developing a good rapport with patients is a must. You will see from the scenario “Pushing on an open door”, that while Dr Smith did not explore

the possibility of a potentially serious diagnosis, Mrs Jones did not pursue a complaint on the basis that she had developed a good rapport during the telephone triage consultation. Tips that may help you develop a good rapport with patients in

the OOH setting are as follows: ■■ Introduce yourself – It is important to introduce yourself clearly at the start of the consultation, as a failure to do so can set the consultation off to a bad start. Many complaints relating to OOH care often make reference to the fact that the doctor did not introduce themselves.

■■ Explore the medical history – In addition to exploring the presenting complaint, given that you do not have access to the full general practice records, it is important to explore the relevant past medical history, current medication and treatment history, allergy history and, where relevant, social and family history.

■■ Explain nature of examinations – It is important to explain carefully the nature and purpose of any examination you intend to undertake. Remember to offer a chaperone in circumstances where you are contemplating an intimate examination.

■■ Explore the diagnosis – You should clearly explain the diagnosis, together with any proposed treatment.

■■ Provide safety-netting advice – You should provide appropriate safety-netting advice, which should include how the patient can re-access the OOH service should they need to do so.

Justify your management When patients contact OOH services it is not unusual for them to ask for a home visit, while in many cases their problem can be appropriately managed either through a telephone consultation or through a consultation at an OOH centre; if there is an adverse outcome, patients will often allege that their request for a home visit was refused. It is therefore extremely important to put yourself in a position to justify your management decision. In the scenario “A disputed visit

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