2. Good clinical care
This section explains the high quality of care that patients should expect to receive. There are comments on the following sections of the GMC's guidance:
Good clinical care must include:
2.a. Adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient.
What this can mean in practice for a disabled person is firstly that the person’s ways of communicating should be established as soon as possible.
The doctor should ask the patient about their condition before examining them. The doctor needs to take account of the disabled person’s impairment but not to the detriment of the patient. For example if a doctor is examining a person who is deafblind they should take account of the communication needs of the patient before they undertake the examination.
This has 2 practical implications which can appear to conflict:
- Not perceiving them purely in terms of their impairment - what is sometimes referred to as ‘diagnostic-overshadowing’.
- Recognising at the same time that the impairment might cause a health inequality which needs to be addressed by some additional action.
For example, a person with a sight difficulty needs non-impairment related services such as cancer screening like anyone else, or they may actually need this more because they may be less likely to detect essential signs of tumours (e.g. skin discolouration or blood in faeces).
A person with a learning disability may need elective services such as family planning advice just like anyone else, but in addition they should receive annual health checks (in line with ‘Valuing People’ national guideline) because as a group they face very high health inequalities that can shorten their life expectancy. They also need more time and a more flexible approach to a thorough examination as many conditions may go unrecognised and undiagnosed due to lack of communication.
It is also important not to make assumptions about a disabled person’s life. For example, women with a learning disability may have an active social life which includes sexual relationships. They should not therefore be omitted from cervical screening simply because of assumptions that they cannot be sexually active or would not understand about sexually transmitted diseases. (see illustration 2.b)
Likewise if the consultation relates to a long term condition which is a disability under the Disability Discrimination Act (DDA) the patient should be listened to with great care. They are likely to be as much an expert on their condition as most front line medical staff.
This can be as simple as considering how and where treatment is to be provided, and what this means for the disabled patient.
For example, a disabled person who has a prosthetic limb attends their yearly appointment and is told they have to have a new leg fitted at a different hospital. Consideration must be given to how the disabled person will get to the appointment. It may for example be easier for them to travel at times in the day when public transport may not be as busy so they are able to find a suitable seat.
There may be no problem at all, but the service provider should at least check this out.
Similarly, will the disabled patient be able to find the location they are being sent to, particularly if they have not been there before? This may be impossible without assistance for some disabled patients.
If a doctor is aware of the access requirements of patients this can save time and reduce missed appointments. For example, a note on a patient’s medical records that a patient with a history of mental health problems may find telephone consultations less stressful for routine follow up discussions can be mutually beneficial for patient and doctor.
A simple note of the access requirements of patients will usually help anyone if they consent to this information being noted and shared.
An illustration of this point is a GP quickly reads a patient’s access requirement note which is attached to the file. She asks her receptionist to ensure that the clinic the person is referred to is aware that the deaf patient has particular access requirements. The clinic then needs to meet any access requirements.
It is also important not to make assumptions about a disabled person’s life. For example, women with a learning disability may have an active social life which includes sexual relationships. They should not therefore be omitted from cervical screening simply because of assumptions that they cannot be sexually active or would not understand about sexually transmitted diseases. They then may require more careful communication and support to consent and undergo such interventions.
3.f. Keep clear, accurate, legible and contemporaneous records of every contact with patients, reporting the relevant clinical findings, the decisions made, the information given to patients and any drugs prescribed or other investigation or treatment provided
As well as purely medical notes and records, it is valuable to have a file note of the mobility and communication requirements of patients. This can be quickly referred to as patients book appointments, attend consultations or as conditions, referrals or treatments are noted.
This is not purely a disability issue but it is also vital for disabled people. Healthcare practitioners should be aware that disabled people may have other complicating factors in their lives, such as English not being their first language, having childcare and, or other caring commitments that restrict their access to out of hours services.
Others may have difficulty in understanding jargon or written text. For example someone who has had a head injury and has a cognitive impairment may prefer to have information to take away and look at rather than responding immediately to information they have just been given.
Having a note of what steps overcome these barriers to the use of services by patients is arguably as useful as their other records.
It will also help reduce non-attendances.
6. If you have good reason to think that patient safety is or may be seriously compromised by inadequate premises, equipment or other resources, policies or systems, you should put the matter right, if that is possible. In all other cases you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them.
Patient safety and the access requirements of disabled people go hand in hand. One of the greatest dangers to disabled patients is probably cluttered or untidy waiting areas, corridors and wards. This can be attended to by any health providers instantly. It can also be a written policy that items are stored in areas that do not cause hazards or restrict access e.g. not storing cleaning materials in an accessible toilet.
Doctors are not always in a position to change these environmental issues. They can, however usually either seethat clutter is removed, or, they have the authority to report such matters.
Ensuring the safety of your disabled patients is essential to providing good access to services. For example, a wheelchair user is unable to move safely from the chair on their own. They may wish to be moved using a hoist. If a hoist is not available, this should be highlighted by medical staff and an alternative found in the meantime by for example, possibly sharing equipment with another department.
Staff should also be appropriately trained in order to use the equipment. For example hearing aid loops may be available at reception but if staff are unable to use them they are ineffectual.
7. The investigations or treatment you provide or arrange must be based on the assessment you and the patient make of their needs, and priorities, and on your clinical judgement about the likely effectiveness of the treatment options. You must not refuse or delay treatment because you believe that a patient’s actions have contributed to their condition. You must treat your patients with respect whatever their life choices and beliefs. You must not unfairly discriminate against them by allowing your personal views to affect adversely your professional relationship with them or the treatment you provide or arrange. You should challenge colleagues if their behaviour does not comply with the guidance.
For example, medical decisions must be taken on the basis of a patients’ clinical condition and should not be influenced by the fact that the patient is a disabled person. For example, a person who experiences mental health problems should not be treated as if they are ‘delusional’, or making up symptoms. These should always be clinically examined. When someone has a serious condition, their treatment should not be restricted by value judgements about their quality of life. This can be particularly prejudicial to disabled people. It is also important to not make assumptions about a person’s quality of life.
Patients always have the right to make their wishes clear. For example that they want to continue receiving life saving treatment where possible. Where a patient appears to lack capacity to make their wishes clear, every effort must be made to ascertain these e.g. sign language interpreters, communicator guides, advocates or checking that they have understood their choices.
The Mental Capacity Act which covers England and Wales is a new framework which can help to determine a patient’s best interests. The Act creates a presumption of capacity and seeks to enable this if it is restricted. It means that the patient is not judged on their disability, even though the disability might affect capacity. It also makes sure that families and carers are consulted and that reasonable steps are taken to check that their views (and any information they give) are consistent with those expressed by the disabled person.
Last Updated: 07 Apr 2010