 
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Journal of the New Zealand Medical Association,
07-July-2006, Vol 119 No 1237
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
When does a specialist assume the “duty of care”
for a patient? The significance of Case 04HDC13909
Frank Frizelle
According to a recently realised decision by the Health and
Disability Commissioner (HDC)1 on the care of a urology patient at Southland
Hospital, a specialist assumes the “duty of care” for a patient when
they receive the referral letter.
This aspect of care has now been clearly defined, and it is
important to most doctors practising clinical medicine. The Commissioner’s
report states:
It
is well recognised within the health sector that there is insufficient public
funding to meet the immediate health needs of all New Zealanders. It is
inevitable that not all patients who require treatment will be able to be seen,
and some patients may spend a significant time period waiting to be assessed and
treated in the public sector. In this environment, it is essential that patients
waiting for assessment and treatment in the public sector receive appropriate
care and management until such time as they are able to be seen.1
He then goes on to say,
...[this
decision] explores the responsibilities of providers in the management of
patients waiting for a First Specialist Assessment (“FSA”) in the
public system. In particular, it examines the relative responsibilities for the
prioritisation and ongoing management of patients waiting for FSA appointments,
and the systems that should be in place to ensure that patients do not fall
through the cracks.1
Many clinicians believe that the responsibility for not
seeing the patient lies with the district health board (DHB) or Government for
not providing the resources for the patient to be seen. They are right to a
point, as the HDC report states:
...under
the Ministry of Health national service specification, DHBs had a duty to
develop, implement, and manage booking systems for all medical, surgical, and
diagnostic services. If DHBs could not meet the ongoing demand for specialist
assistance and advice within 6 months of referral; the specification required
DHBs to prioritise referrals; notify referrers and patients of the ability or
inability to provide services within the minimum standard of 6 months; and
provide referrers with information that indicated the level of need or priority
that could be serviced, together with referral or management guidelines to
enable general practice to manage the patient’s plan of care and review or
reassess the patient’s condition as appropriate.1
However at the individual patient level the clinician has a
responsibility that cannot be abdicated. This is what has been defined by the
Commissioner in his report, when he states:
A
clinician does not have to be in direct contact with a patient to owe that
patient a duty of care, and a clinician can accept a patient into his or her
care without ever seeing that patient, a specialist assumes responsibility for a
patient for the purposes of establishing a duty of care when the information in
the referral letter is considered, and a priority allocated.1
The intriguing aspect of this HDC report is that the above
statement is referenced to a discussion document released by Dr David
Geddis—Aspects of a Doctor’s Duty
of Care.2 This controversial discussion document appears not to have been
accepted by many professional groups. Dr Geddis wrote this document for the
Medical Advisers Group as a private individual before he started work for the
Ministry of Health. It was firmly rejected by the Council of Medical Colleges
and the New Zealand Medical Association who were both sufficiently concerned
about the document for the Chairman to inform the then Director General of
Health, Dr Karen Poutasi.3 It is of great concern that this document, of
uncertain status, has become a document of record because the Commissioner has
used it as a critical part of his argument.
Of course the Commissioner is correct in going on to point
out the reality of the system we work in with his comments:
Doctors
have a responsibility to ensure that the process for assigning priority is
appropriate. Referrals to a service with limited resources should be seen in
order of priority and a patient should receive treatment in accordance with his
or her assigned priority. Prioritisation systems should be fair, systematic,
consistent, evidence-based, and transparent.
These comments are entirely consistent with the New Zealand
Medical Council’s own statement on “Safe Practice in an Environment
of Resource Limitation” of which some points are outlined below
However it now appears that the
waiting-list situation may have deteriorated to the point where, despite
patients being correctly prioritised, patients with significant degrees of
illness can’t get treated in the public sector in reasonable timeframes.
The previous Minister of Health stated in the NZMJ4:
If
DHBs are not providing timely services, they need to account to the Ministry of
Health and the Minister for the reasons. Sometimes, for example, workforce
shortages or industrial action make it more difficult, but DHBs are expected to
take all action to meet their signed agreements with the Minister. At times,
this can include use of the private sector...the Minister and Ministry can only
take rapid action to address problems if they are kept informed of the latest
issues...(The Minister ) is keen for DHBs to be more proactive in terms of
identifying potential problems so they can be averted.4
With this in mind, one of the most significant activities of
the DHBs has been to remove patients from the waiting lists. A total of 8108
patients were removed from surgical waiting lists between January 2005 to
January 2006.5 In the last few months there have been many more reports of the
removal of large number of patients from waiting lists. However the DHBs do not
seem to be responsible on an individual patient basis—the doctor
is—and a DHB’s response is to remove people from the waiting list to
fulfil the ministerial agreements about achieving manageable waiting lists.
The only time DHBs appear to become involved with individual
patient care is when the patient complains via the media, their Member of
Parliament, or the Minister of Health.
So, in summary, doctors have been made responsible for a
job, without being given the tools to do it.
Author information:
Frank A Frizelle, Editor, NZMJ, Christchurch
Correspondence:
Professor Frank A Frizelle, NZMJ, Christchurch School of Medicine, PO Box 4345,
Christchurch. Fax: (03) 364 1683; email: FrankF@cdhb.govt.nz
References:
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|