Nurses as patients — where should you register?

Is it a good idea for practice nurses and other surgery staff to be registered as patients where they work? Do the pros outweigh the cons? And what happens if you get really sick? How impartial can your doctor be to give good objective care?

The doctors I work for are also my family doctors. I had been registered with them for some time, even before going to work at the surgery. Ever since being part of the practice team for the past 10 years or so, I have been happy to see the doctors for relatively minor conditions and illnesses. It's all been very professional, confidential and straightforward. I've seen my nursing colleagues for cytology screening and the GP has sorted out my contraceptive needs. It's extremely convenient, there's no embarrassment - job done. I've even been guilty of getting the Health Care Assistant to take my blood outside of an appointment slot — we've all done it in our team. And, there are times, I confess, I have asked the GP to issue a repeat script for my family. As a team, we often look after each other in the practice. I know many of my nursing colleagues working in other practices do the same. We've all had the 'can I just see you quickly' moment from staff, which, on occasions, can turn into a 30-minute consultation. We've seen our colleagues who are not even registered as patients at the surgery. It happens to the GPs, too. But is this really good practice? Is there any harm in all this?

How would I feel, really feel, if I had something serious, physically or mentally? What if I have some prolonged rectal bleeding, changing stool patterns and weight loss. The very thought of one of my medical colleagues performing a rectal examination makes me recoil with fear. Just thinking about it makes me concentrate on improving my pelvic floor technique. And if that wasn't bad enough, to make small talk with the doctor as you grab a cup of coffee or have a chat over the QOF targets afterwards would be extremely uncomfortable. In reality I'd just have to get on with it.

Looking at things from another angle — what if the job was actually getting me down? Not the occasional 'bad day at the office' that we all get from time to time. But when it really gets too much, when it could potentially affect my ability to practise safely and effectively. Who do I go to see when the workload becomes simply overwhelming — if I was constantly being berated for not reaching my targets, for running late over and over again and with the patients getting more and more demanding and complaining? What if, in addition to that, if the GPs start to give me a really hard time, I feel like there's no support and staff morale drops to an all time low. Then there's the new computer system to deal with. As a result, I'm not sleeping, I'm not eating, I'm grumpy and I've got a constant headache. I'm exhausted and I feel like bursting into tears all the time. Who do I go and see then? I don't want to be at work but one of the nurses is on holiday and the practice manager is muttering about not spending any more money on locums and we have to all pull our weight. Who do I go and see? Suddenly, this professional, confidential and straightforward relationship I've previously had with my doctors would seem awkward, difficult and misplaced. They are my employers and essentially I would be telling them that they have been responsible for the stress and anxiety and at the same time, expecting them to help me get through this from a clinical point of view. It doesn't matter how caring, sensitive and understanding they may be to my plight, there will inevitably be a conflict of interest between their role as my employer and that as my clinician. Can they really provide good objective medical care and remain impartial?

PROFESSIONAL GUIDANCE

It's worth looking at what professional guidance there is for GP practices and whether having staff on their books, as patients, is good practice. Neither the General Medical Council (GMC) nor the Medical Defence Union (MDU) has any specific policy or guidelines in relation to this area. Certainly the GMC's Guidance on Good Medical Practice (2009) suggests that doctors themselves should not be registered at their own GP practice, in order to have 'access to independent and objective medical care'.¹ Indeed, it recommends that doctors should refrain from treating family or friends. But staff? Speaking to the GMC, they suggest that there is no actual objection to doctors treating their staff provided that a professional relationship and objectivity are maintained.² The MDU's response is more cautious. They feel that there could be potential difficulties and conflicts by treating staff. In addition, they suggested that it would be difficult to maintain a separation between medical health and employment.

What about the Nursing and Midwifery Council (NMC)? From the perspective of nurses prescribing for other members of staff, the standards of proficiency set out by the NMC clearly stipulate that nurse prescribers should not prescribe for 'anyone with whom you have a close personal or emotional relationship'³ which could include prescribing for colleagues. The NMC's Code reminds us of our professional need to remain impartial and the possibility that treating staff could challenge this impartiality.⁴

How does the Royal College of Nursing (RCN) feel about nurses being patients at their place of work? Again the RCN has no firm policy or guidelines on this issue, although the RCN helpline did advise me that nurses who are registered at their own practice have the potential to abuse their privileged position of having 'instant' access to personal medical treatment. Also, they urged me to consider the possible dilemma for GPs as both their doctor and employer and the conflicts it could potentially bring, especially with work-related stress.

THE DILEMMA

So I now have a dilemma. I like my surgery and when I have seen the doctors professionally they have always treated me as they do any other patient — with mutual respect, appropriate care and in confidence. Some doctors believe that having staff as patients is simply a part of a rural GP's caseload. There are times when they notice how poorly you are and see you trying to battle on with the job. They are good at the pastoral care of their staff. It's so much easier to make appointments for the family as well without going through the usual formalities. Have you ever tried to ring up your own practice? The practice I am in is fairly rural so to move away would be quite an upheaval. Without doubt, it's just so convenient. I'm sure for some nurses in particularly rural areas it could be a complete nightmare or almost physically impossible if they had to change practice. As it stands now with several practices in our area, new staff are being asked to register elsewhere, if they are not already, as there is increasing concern about the potential conflicts involved.

But would my employer really be the right person to meet any work-related stress problems or mental health needs? Could I be assured of confidentiality and fairness? What if I disagreed with the doctor's recommended advice or treatment for any condition? How easy would it be to challenge the prescription? I might find it easier to see another GP within the same practice but that might be awkward and put everyone involved in a difficult and uncomfortable position. There are certainly many issues that could make the doctor-patient relationship a difficult one when the patient is also employed by the doctor.

Good practice tells me I really ought to register elsewhere to get appropriate, independent, objective and impartial care. I could separate my working environment and my personal health needs. If I had to have time off work — whatever the reason — the GP I'd see wouldn't have another agenda, being concerned about the impact on the rest of the team if I had time off or worrying about how much it might cost them in overtime. I would only need to share with my work colleagues what I wanted to share. I wouldn't be fearful that the reception team or secretary might take a close interest in any past medical history if they had to write a referral, or indeed be able to see my results. My right to confidentiality wouldn't be challenged. It would remove any risk of potential conflict between the doctors' role as my clinicians as well as my employers. It also has to be said, that if there were ever to be a fitness to practise issue or disciplinary proceedings, then having my boss as my doctor would be wholly inappropriate.

SUMMARY

In the absence of firm guidelines, individual practices need to make the decision to allow their staff to be registered as patients or not. Without doubt, there are potential risks of conflict. Available guidance advocates that to provide good medical care, a practitioner needs to be able to be objective, impartial and wholly confidential. The trust built up between the doctor and patient may be challenged under certain circumstances within the working environment. The suggestion is that it is not best practice to have staff registered as patients. Staff, however, may feel let down if they are asked to re-register at another practice, especially if they have been with their GP for many years and have had a positive doctor-patient relationship. Equally, some doctors are happy to accept the fact that staff and their families living in-catchment are part of a rural GP's workload. This may be especially true for staff living in very rural areas where changing to another surgery is effectively unrealistic and impractical. There are potential serious consequences where we, as doctors' employees, register as patients and we need to be aware of the potential conflicts of interest and difficulties that can arise, especially with long term physical and mental health conditions. Ultimately, the decision as to whether or not staff should be treated medically by their employer requires very careful consideration.

REFERENCES

1.General Medical Council. Guidance for Doctors. Good Medical Practice. London: GMC, 2006 [updated 2009] ; p. 34. Available at http://www.gmc-uk.org/static/documents/content/GMP_0910.pdf

2. General Medical Council. Guidance for Doctors. Good Practice in Prescribing

Medicines. London: GMC, 2008 Available at http;//www.gmc-uk.org/static/documents/content/Good_Practice_in_Prescribing_Medicines_0911.pdf

3. Nursing and Midwifery Council. Standards of proficiency for nurse and midwife prescribers. London: NMC, 2006

4. Nursing and Midwifery Council. The code: Standards of conduct, performance

and ethics for nurses and midwives. London: NMC, 2008.