Diabetes presents a medico-legal challenge for GPs, nurses and specialists. This can leave the clinician vulnerable to a complaint or claim.
Problems can arise in the case of:
- failure or delay to make an initial diagnosis
- failure or delay to diagnose and/or treat a later complication
- poor monitoring or providing inadequate care, eg not acting on test results or carrying out regular screens and checks
- medication errors
- patients refusing to cooperate with dietary advice and medication plan.
In general, delays in diagnosis are one of the most common reasons for complaints and claims against GPs. In many cases, the patient's condition may not be immediately obvious, or there may be several possible explanations for a patient's symptoms.
Despite these difficulties, it is expected that doctors will appropriately investigate classic symptoms such as increased thirst, weight loss and tiredness, particularly if the patient has a family history of the condition.
Because patients with diabetes can develop serious complications, such as retinopathy, neuropathy and cardiovascular disease, ongoing monitoring is essential.
GMC guidance states that you have a duty to ensure 'suitable arrangements are in place for monitoring, follow-up and review, taking into account of the patient's needs and any risks arising from medicines'.
GP practices should have adequate systems in place to monitor chronic conditions, such as diabetes. Systems should take into account:
- whether the practice can deal effectively with patients who fail to attend monitoring appointments or blood tests
- handling incoming correspondence to ensure blood test abnormalities or changes to therapy are actioned promptly
- regular audit of high-risk medications.
The doctor-patient relationship
A diagnosis of diabetes is often distressing and disruptive for patients, requiring them to change their lifestyle and adhere to treatment and monitoring regimes.
The National Institute for Health and Clinical Excellence (NICE) recognises that diabetes care can be complex and time-consuming for clinicians, but advises doctors to prioritise patient education and self-care. NICE recommends that doctors provide patients and their carers with structured education at time of diagnosis, explaining to them that this is a vital part of diabetes care. This should then be followed by regular reinforcement and review.
If patients refuse to attend review appointments, you should explain the risks they are taking and can offer them a second opinion. Ultimately, doctors have an ethical duty to respect a competent patient's decision to refuse investigation or treatment, even if you think that decision is wrong or irrational.
The MDU strongly advises doctors to make a detailed record of their interactions with patients in such cases, and to document any assessment made of the patient's capacity to decline treatment.
Risk management advice
- Take a thorough history and record details of your examination, along with the differential diagnosis and management plan.
- Record any relevant negative findings, as well as positive ones.
- Make sure the patient is aware of the likely timescales for symptoms to resolve, or for treatment to take effect. Advise the patient to return if symptoms continue.
- Familiarise yourself with the relevant national guidance on diabetes care from NICE and SIGN. Diabetes UK also produces guidance and resources.
- Check your systems for monitoring patients with chronic conditions to make sure patients with diabetes are flagged and receive regular appropriate check-ups and screening, such as HbA1C levels, cholesterol levels, kidney function, eye screening for diabetic retinopathy. Diabetes UK has identified 15 healthcare essentials for patients to follow up with their doctor.
- Consider implementing a computerised warning system to flag patients you are concerned about, so that they can be followed up.
- Contact diabetic patients who repeatedly fail to attend review appointments. Give them enough information to make sure they are fully aware of the benefits of monitoring, and the risks of not attending reviews.
- Review long-term medication and check that patients are adhering to drug regimens.
- Where care is shared between primary and secondary care, have a protocol in place setting out who is responsible for prescribing, monitoring and follow-up.
- Use your practice's adverse incident reporting system to record and analyse delays in diagnosis or other problems, to see if improvements can be made in the interests of all patients.
This guidance was correct at publication 26/03/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.