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Medico-legal - No decisions about me without me

Dr Stephanie Bown explores what greater patient choice might mean for GPs and how they can prepare.

Doctors are already expected to impart complex information in a way their patients can understand (Photograph: JH Lancy)
Doctors are already expected to impart complex information in a way their patients can understand (Photograph: JH Lancy)

While the government's health reforms continue to cause controversy, one principle that remains at the forefront is patient choice. This is not a new concept, but the increased focus will undoubtedly mean changes for you and your practice.

Here is what GPs might expect to see, and the steps you can take to prepare for increased patient involvement, choice and expectation.

  • Respond to all comments, good or bad.
  • Avoid being defensive in your response - it helps to have an objective review.
  • Avoid 'stock' answers.
  • Suggest that those who have left anonymous comments, contact the practice to discuss further.
  • Be careful not to breach confidentiality - explain this as the reason for not being able to comment fully on the website.

Risks and weaknesses
Identification of risks and weaknesses will be critical if GPs are to adapt to an environment of more patient choice and expectation.

For example, increased dialogue with patients must be reflected by comprehensive documentation of those discussions. If a patient is more involved in these decisions, there may also be increased requests to access their records.

So reviewing your record-keeping processes will help.

Poor communication is linked to 70% of clinical negligence claims. Increased involvement of patients in their own care will make more demands on your diplomacy and negotiation skills. Increasingly, well-informed patients, having researched their conditions, may challenge you; this can often lead to time pressures, contributing to dissatisfaction and frustration on both sides.

Remember that effective communication involves listening, counselling, debate, information sharing, negotiation and accurate documentation.

It is already a principle enshrined in case law, the Mental Capacity Act 2005 and GMC guidance that clinicians must provide sufficient information in a way their patients can understand.

Doctors are already expected to impart complex and upsetting information to patients whose understanding and desire to be involved in decisions will vary greatly, not least due to social, ethnic and religious background.

GPs must be mindful that not all patients wish to be actively involved in all clinical decisions - and that too much choice can lead to indecision and confusion - yet you are obliged to provide patients with enough information to make an informed choice.

Patient expectations are increasing, perhaps, driven by media coverage of clinical negligence and accessibility of information online. NHS Choices offers patients an avenue for venting their anger when they perceive their expectations are not being met.

Although having negative patient comments posted publicly in this way can be distressing for a practice, NHS Choices is not going away, so practices need to turn this to their advantage (see examples below).


Look at these contrasting responses to a hypothetical complaint posted on an online forum and consider the impression they create:

  • The concept of this forum is entirely flawed, as anybody can write anything about any practice, good or bad, with absolute impunity... Since you choose to hide behind the title 'anonymous' rather than write to the practice in an open and fully attributable way, I have little alternative but to dismiss your comments as unhelpful and unsubstantiated.
  • I am sorry if you felt that the doctor's appointments are sometimes a bit rushed, but in order to try to keep our waiting times as short as possible, we do aim to keep the appointments to strictly no more than 10 minutes. Sometimes, of course, appointments do run over and that is when you are kept waiting. We are always working on this and hope, going forward, that at the very least we will keep you better informed of possible waiting times.

Remember, your response will be seen by everyone, so make sure it puts you and your practice in the best light by showing that you are open to feedback and prepared to improve the patient experience.

Medical Protection Society case experience shows that the number and value of clinical negligence claims against GPs continue to grow significantly, while the NHS Information Centre revealed that the number of written complaints against family health services in England grew by 7% between 2009/10 and 2010/11.

As an example, it is proposed that patients will be able to choose which GP practice they register with, regardless of where they live, and choose between consultant-led teams for secondary care.

If adopted, this could pose issues with continuity of care and expectations about access to the preferred practice. Managing patient expectations will depend on communication skills.

Raising patient expectations by empowering them through choice will provide ethical challenges in an NHS with limited resources.

However, if 'no decision about me without me' becomes a reality, then the need for open communication and strong negotiating skills will become more urgent than ever.


These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Review your medical record-keeping processes and consider what could aid documentation of comprehensive notes, such as using a dictation machine.
  • Provide decision-making aids to patients, such as questionnaires, information booklets, decision boards, audiovisual material and interactive web-based tools.
  • Your practice will benefit from keeping patients informed, having a robust complaints procedure and, if you have not already done so, establishing a patient participation group.

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