Professional guidance
The relevant professional guidance is as follows: from GMC Good Medical Practice (GMP), paragraph 97: ‘You must, wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship‘;
and from the GMC’s supplementary document, Good Practice in proposing, prescribing, providing and managing medicines and devices, paragraph 66: ‘Wherever possible, you must avoid prescribing for yourself or anyone you have a close personal relationship with.‘
There is no specific comment within the updated GMC GMP in terms of registration with a GP. The GMC’s supplementary document, Maintaining Personal and Professional Boundaries states at paragraph 3 that: ‘appropriate professional boundaries are essential between medical professionals and their colleagues‘.
These paragraphs, and other guidance that may become relevant (such as that patients are properly examined where necessary), are designed to ensure objectivity in professional practice and prevent the care that any patient receives being influenced by other (and from a clinical perspective, irrelevant or specious) considerations that may affect decision-making.
Close personal relationships
This can be very difficult to achieve if you are personally related to, or in a personal relationship with, a person who is also your patient. However, although there is no further definition of “close personal relationship” within GMP, clearly the existence of other relationships, such as that of an employer and employee, may affect your objectivity in terms of your professional care and decision-making and in this context can be considered as creating such a relationship.
Patients who are employees
There are also a number of issues which may complicate a doctor/patient relationship, if the patient is also an employee. These include:
- Ensuring an additional level of security to prevent the employee patient records being
inappropriately accessed by colleagues. - Balancing the role as a GP and employer if you are made aware of health issues that may affect the employees operational working, or, the risk that a patient may not fully reveal health issues because of this concern, or a more general reluctance to discuss
potentially sensitive health issues with a colleague. - Agreeing absence from work certification, which again may mean, as a GP, it is difficult to be objective. This is compounded if concerns require an Occupational Health Assessment.
- Dealing with disciplinary, performance management and/or grievances in such situations.
LMC view
Whilst there are many attractively remote areas within the Surrey and Sussex Confederation area, there are very few geographies which fall solely within one practice’s boundary. The LMC recommends that in the very occasional circumstance in which an individual and/or their family does not have a choice and works at the sole practice involved, that neighbouring practices make an exception to their registration policy if this is necessary to allow a patient’s registration away from a place of work.
The LMC recommends that practice colleagues have a policy that precludes newly appointed staff members from being registered at the practice at which they are starting work and makes clear that they will be unable to remain registered if they take up such employment. If existing staff members are registered as patients, the LMC recommends that partners discuss the situation with the relevant staff and seek to agree a reasonable timeframe for re-registration, offering to assist with this process if requested. It is important to note that deregistering such a patient for this reason would be outside the Regulations. However, the practice can explain the reasons for its policy, as outlined above, and why those considerations are important, with a view to encouraging pre-existing staff to choose to re-register elsewhere.
Prescribing considerations
GPs should note that both NHS England and the GMC regard self-care, including prescribing, as a significant professional concern, as it is seen as reflecting a lack of insight into the fact that doctors cannot objectively assess and manage their own health, and, additionally, cannot be their own judge of their medical fitness in the context of their professional work. This extends to those with whom the doctor has a “close personal relationship”, which is normally other family members. Obviously, in an emergency, this does not apply. In other circumstances, NHS England and the GMC expect doctors to consult other practitioners appropriately. Other colleagues may extend a professional courtesy in terms of, for example, timings, but it is essential that in terms of undertaking an assessment, evaluation of care and treatment, and discussion of options such as further investigation and referral, GPs are treating in the same way as other patients. Colleagues are also entitled to the same confidentiality arrangements as other patients.
GPs should note they can be expected to be asked at their NHS appraisal whether they are registered with an NHS GP and to confirm this is not at practice(s) where they work.