The medico-legal pitfalls of managing long term conditions

Posted Jun 16, 2017

Primary care is increasingly seen as the most favorable setting to deliver care for people with long term conditions (LTCs) because it is ‘accessible, is efficient, and can tackle inequalities related to socioeconomic deprivation.’¹ However, delivering this care can be challenging as very often those with LTCs have complex needs. It is essential to manage these challenges to ensure patient safety.

An LTC is defined as a ‘condition that cannot, at present be cured; but can be controlled by medication and other therapies’.²Examples of LTCs are diabetes, heart disease and chronic obstructive pulmonary disease. There are 15.4 million people living with a long-term condition in England and numbers are expected to rise, due to an ageing population and unhealthy lifestyle choices. The Department of Health estimates that the care of people with LTCs accounts for 70% of the total health care spend in England and also accounts for more than 50% of all GP appointments.²

The management of LTCs is a key part of current nursing policy and practice, and increasingly an integral part of the practice nurse role. As the practice nurse’s autonomy increases in the ever-changing general practice environment, so does the risk of litigation.

Healthcare litigation is increasing across all providers and patients rightly expect high quality, safe care. Therefore, it is paramount that practice nurses are aware of the risks and take steps to mitigate those risks, especially those related to managing LTCs.

KEY LEARNING POINTS

After reading this article you should be able to:

Explain what is meant by a LTC.
Have a better understanding of the potential risks in managing LTCs in general practice.
Identify the risks/challenges and be able to put systems in place to mitigate the risk of managing LTCs.

CLINICAL NEGLIGENCE CLAIMS RELATED TO LTCs

A study of Medical Protection claims identified that 16% of claims which involve nurses working in general practice relate to chronic disease management.

A review of Medical Protection high value (£1,000,000+) clinical negligence claims revealed that a poor standard of chronic disease management is a frequent factor.³Deficiencies in chronic disease management made up 11% of these very high value claims, identifying that over time, suboptimal management of LTCs can cause more insidious development of complications.

Systems failures were found to be a main contributory factor, particularly:

Inadequate monitoring of the disease progression.
Inadequate assessment of the patient’s condition.
Failure to adjust treatment where necessary.
Failure to act on tests results.
Failure/delay to refer patient to a GP/specialist.

Examples included:

Inadequate monitoring of renal function in a patient with hypertension, leading to the development of chronic renal failure requiring dialysis.
Inadvertent continuous long term use of oral steroids in the treatment of severe asthma, leading to osteoporosis, back pain and disability.
Failure to monitor a patient’s full blood count during carbimazole treatment, leading to the development of neutropenia.

Peripheral ischaemia accounted for 7% of these very high value claims, many of which were related to diabetes. Issues identified included:

Failure to diagnose ischaemia.
Delay in the treatment of ischaemia.
Inadequate treatment of ischaemia.

There is specific NICE guidance on the monitoring of leg ulcers and peripheral circulation in patients with diabetes, specifically recommendations on referral timelines for diabetic foot problems.⁴This should be incorporated into the practice protocol.

Practices must ensure that there is a robust system for appropriate monitoring of LTCs, which ensure that practices have the necessary:

Protocols for the management of LTCs.
Systems to ensure that blood monitoring and reviews are undertaken.
Systems to ensure test results are reviewed and advice is communicated to the patient, including the stopping or adjustment of medication/treatment.

When undertaking a LTC review, you may find it beneficial to review the following:

The disease/condition:

Check the patient’s understanding
Monitor disease progression.

Monitor and review:

Adherence to treatment (compliance, concordance)
Effectiveness of treatment
Side effects (symptoms)
Adverse effects.

Secondary prevention:

Check the patient’s understanding
Assess and monitor the risk factors.

Effect on the patient:

How is the patients’ mood? Feelings of depression?
How is the illness/condition affecting the patient’s life/work?
How is the illness/condition having an effect on family/carers?

PROTOCOLS

Clinical protocols represent the framework for the management of a specific disorder or clinical situation and define areas of responsibility. They reduce variation, maintain the quality of patient care and are documentary evidence of the standard of care to be provided.

Your practice protocols should address/include the following:

Identify the practice clinical lead for each LTC, ideally a GP with an interest in the disease.
Knowledge and skills framework to assess clinical competency of the nurse.
Risk assessment of the procedure and environment.
Documentation and record keeping.
Consent.
Identify who carries out key parts of the care or treatment.
The use of Patient Group Directions and Patient Specific Directions where appropriate.
Evidence/research based in line with national guidance, e.g. NICE,5 National Guideline Centre,6 British Thoracic Society guidelines.⁷
Reflect local services.
Define the circumstances where patients are referred on from nurse run clinics to either a GP or directly to secondary care.
Describe the practice’s criteria for stepped increases in therapy.

Protocols should be clearly marked with date of creation, ratification, future review, and the version number of the policy. The protocol should be signed off and authorised by the lead clinician. They should be reviewed annually, and outdated protocols should be retained for at least eight years, in case of litigation. Failure to retain copies of historic policy documents can make it difficult for organisations to successfully defend claims. Claims can date back many years and it is essential that the practice is judged against the expectations and knowledge at the time.

PROFESSIONAL ACCOUNTABILITY

In an era of increasing challenges in general practice, particularly due to pressures on workload and rising service demand, it is essential that nurses are trained and competent to undertake the roles required of them and are working within their scope of practice. The Nursing and Midwifery Council (NMC) states in The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives (March 2015):8

Para 6.1: ‘Make sure that any information or advice given is evidence-based, including information relating to using any healthcare products or services.
Para 6.2: ‘Maintain the knowledge and skills you need for safe and effective practice.’
Para 13.3: ‘Ask for help from a suitably qualified and experienced healthcare professional to carry out any action or procedure that is beyond the limits of your competence.’
Para 13.5: ‘Complete the necessary training before carrying out a new role.’

INDEMNITY

In July 2014, it became a legal requirement for nurses and midwives to hold an indemnity arrangement and the NMC updated the Code to reflect this change.⁸Many nurses will be covered through their employer; however, nurses have a responsibility to check what is covered by their employers’ indemnity. It is the professional responsibility of each nurse to ensure that they have adequate arrangements in place which reflect the risks associated with their scope of practice, in the event that a claim is made against them.

CONCLUSION

Globally the population is living longer and presenting with multiple comorbidities that demand increasingly complex interventions, therefore the prevalence of LTCs will continue to grow. Patient expectations are changing and this mean that patients may be more likely to be dissatisfied and complain about their care.

It is likely that general practice will increasingly be the focus of the care of these patients and it is imperative that practices adopt a culture of safety and ensure safe systems for monitoring and managing patients with LTCs.

REFERENCES

1. Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition

2. DH, Improving the health and well-being of people with long term conditions (2010).

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111187.pdf

3. Medical Protection Casebook, High value claims (May 2016)

http://www.medicalprotection.org/docs/default-source/pdfs/casebook-pdfs/uk-casebook/uk-casebook_may_2016.pdf?sfvrsn=12

4. NICE guideline [NG19], Diabetic foot problems: prevention and management :

https://www.nice.org.uk/guidance/ng19/chapter/1-Recommendations#diabetic-foot-problems-2

5. National Institute for Health and Care Excellence (NICE):

http://www.nice.org.uk/

6. National Clinical Guidance Centre (NCGC):

http://www.ncgc.ac.uk/