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THIS year, the UK National Health Service will introduce a “duty of candour’, a new contractual requirement on health care providers to “tell their patients if their safety has been compromised, apologise, and ensure that lessons are learned to prevent them from being repeated”.
It reminds me of the errant schoolboy being marched up to the front door of the neighbour’s house to apologise for the broken window.
The UK’s new requirement does not enjoy universal support. Respondents to the NHS consultation process were 50% for and 48.4% against the proposal. Nevertheless, it is going ahead.
Interesting times ahead in the NHS … yet again.
Australia does not need to follow suit. We have safeguards, checks and balances, and new quality and reporting agencies aplenty.
Even before the advent of our new agencies, we have institutionalised morbidity and mortality audits, perinatal and infant mortality checking, root cause analyses for adverse events and near misses, together with a medical indemnity insurance industry that has encouraged us to be open and clear with our patients.
Offering a sincere expression of regret for an adverse outcome and providing a clear explanation is not an admission of liability.
Why should we legislate for common sense?
The doctor–patient relationship is unique. It is built on honesty and trust. It is our job — our calling — as doctors to provide the best possible care for our patients throughout their lives. We provide that care and advice based on our special skills and knowledge.
If there are adverse events, we recognise them, take responsibility for them, and seek to rectify them — in concert with the patient — and put in place mechanisms to avoid recurrence of such events.
To this end, I think we are well ahead of the UK and the NHS.
The Medical Board of Australia produced Good medical practice: a code of conduct for doctors in Australia. The AMA had a hand in its publication, and it encapsulates the views of the profession in many areas.
Formally adopted in 2010, the code describes what is expected of all doctors registered to practise medicine in Australia. It sets out the principles that characterise good medical practice and makes explicit the standards of ethical and professional conduct expected of doctors by their professional peers and the community.
The Medical Board code states clearly that, in the event of adverse events, doctors should explain to the patient as promptly and fully as possible what has happened and the anticipated short- and long-term consequences.
The code also states that doctors should acknowledge the patient’s right to complain and work with patients to resolve the issue, where possible.
Importantly, the code calls on doctors to provide a prompt, open and constructive response, including an explanation, and, if appropriate, an apology.
It is also a companion piece to the AMA’s code of ethics.
The AMA’s code says that doctors must first consider the wellbeing of the patient, treat your patient with compassion and respect, and approach health care as collaboration between doctor and patient.
This is at the core of medical practice in Australia. We have an intrinsic duty of candour, and more.
It will be interesting to observe how our colleagues in the UK respond to being obliged by law to do what they surely do naturally and instinctively.
Dr Steve Hambleton is the federal president of the AMA.
Posted 18 February 2013
The moment that a third party intervenes between the patient and the doctor the trouble starts. With rationing of medical services by government or HMOs, constraints inevitably are placed on all communications between doctor and patient. The doctor may be prevented from advising the patient that there are reasonable and appropriate treatments available which the insurer will not fund because it is diverting funds increasingly to its bureaucracy. The shameful situation which prevents employed doctors from telling the truth to patients is intrinsic to third-party intrusion. “Commercial in confidence” inevitably turns out to be “skulduggery in secret”. In an open society all transactions should be transparent and accessible by all for public audit. Furtive bureaucrats and lying politicians seek to prevent access to the truth by those for whom they work or purport to represent. The greatest trap to avoid is that of clinicians taking upon themselves the role of rationing services to patients to implement bureaucratic policies and government rationing. In that way they make themselves the fall guys and divert responsibility from those who cause the trouble. This is the inevitable outcome of Medibank and Medicare which are based on the UK NHS.
There has been some discussion regarding the candour with which the patient’s condition (and contributing factors) can be discussed with the patient, eg, that it is the patient’s weight that caused the osteoarthritis of the hip or his poor diet that contributed to the infarct. Are patients expected to “admit” this sort of thing (when an adverse outcome occurs) with the same candour that doctors are now apparently expected to ” ‘fess up” when adverse outcomes occur.
Thanks to Dr Hambleton for this piece. I agree with the points made and the links to essential references for doctors is very useful.
Drs the world over have always had a professional duty of candour (expressed in various ways) and always will. Who would see a doctor that kept secrets from the person being cared for?
But there is a big problem both in the UK and here that compromises this duty and leads to horrendous and unsafe patient care. As Dr Hambleton says there are plenty of safeguards to police the professional standards of Doctors – that is not the problem.
The problem in Australia and more so in the UK is the conflict between employment law and this professional duty of candour.
Salaried doctors are usually effectively gagged from vigorously highlighting unsafe systems of care as doing so is against their employment terms. You only need to compare the Medical Board codes of conduct with the public service codes of conduct to see this.
Like in the UK, the pattern of the response to doctors raising concerns about patient care is that the employer will deny and refute that any problem at all exists and then threaten those doctors that dare to raise concerns with repercussions for their employment and by inference their career. From this there is a culture of doctors living in fear of failing to act to protect patients or fear of retribution from their employer.
Negative employment and career repercussions for doctors being candid about patient care are far more immediate and material for a doctor than being silent. However the consequences for patients will likely be extreme in some way. What is the right thing to do? This explains the 50:50 split in surveys on candour that Dr Hambleton describes I think.
This conflict must be fixed. The existence and use of employment law to prevent doctors being candid with the people they care is very wrong in my view.