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Your Right? To a Second Opinion

Your Right to General Practitioner Medicine 1. GP Surgery Registration.

Everyone in the UK (not just England) has the right to register with a GP surgery and you may pick any surgery as long as you live in the catchment area. This is true even if you are not a UK citizen (in fact even if you intend to stay less than 3 months). A GP also has some rights not to accept you onto the list of patients, however, these exceptions are very exceptional; if the GP can demonstrate that the practice register is full, or that the patient is outside of the practice catchment area, or indeed, that you have behaved in a manner which is threatening, violent or abusive toward staff then a refusal to register is possible. If you suffer mental health problems and you are already in detention then special arrangements apply.A GP cannot however discriminate on any grounds regarding religion, pregnancy, maternity, sexual orientation or disability. In any event, all refusals to register are open to review by NHS England and anyone suffering a refusal should seek a) written reasons from the GP and then b) put those reasons before NHS ENGLAND for resolution.In circumstances where a patient has been abusive or violent towards staff and a warning has been given or if the behaviour is such that a warning is simply not appropriate. Then the GP will contact NHS England direct. NHS England will then decide if the patient should be removed and will notify the patient of that removal. In most circumstances (except for one of violence) the patient will be given a 8 day period to arrange registration at an alternative practice and during that time the existing GP will see the patient (there may be conditions). In emergency situations even violent or abusive patients must be treated. NHS England (and I should add other equivalent National NHS bodies) are scathing of GP’s who strike patients off the list without very good cause and GPs who find themselves having regular “tiffs” with patients can attract very senior and very unwanted attention. Trust me on the whole GPs are loath to strike off a patient without very good cause.

2. Individual GP’s Everyone as indicated above has the right to registration at a surgery, however, nobody has the automatic right to be seen by your own GP. You can of course book an appointment with your GP in the reasonable expectation of seeing him or her but at that appointment there is no obligation for that specific GP to be there as long as adequate professional cover is in place. In other words, “you can ask but cannot insist”. Please do not kick off about this to the receptionist, you just don’t have the right to be seen by your first choice. GP’s will tell you that this is among the hottest areas of patient conflict in GP practices and they do strive wherever possible, to ensure that a patient gets their registered GP at any consultation, however, as in any other area of life, things sometimes become frustrated. The existence of the “suitable alternative rule” is helpful only with unhelpful patients, most have the presence of mind to accept the substitute or rebook and not to create conflict. In an emergency situation, you must be treated, regardless of whether you are registered with a GP surgery or not. No GP can refuse to administer emergency care (or charge for it) because a patient is not registered with them or their practice. Changing a GP is much easier that it used to be. Essentially you change your GP at the drop of a hat and you do not have to give a reason. Each Clinical Commissioning Group will have a protocol for changing GPs and they will tell you how to do so. Most GP surgeries secretary or administrator will be able to put you in contact with them. You don’t have to tell anyone why, if you don’t want to and you never have to tell in order to get a change, that is a myth. You can get a list of GP’s from NHS Choices online at https://www.nhs.uk/Service-Search/GP/LocationSearch/4 or by visiting https://www.healthwatch.co.uk/ where you can undertake a search. If you don’t do modern internetty things you can call up your local NHS Clinical Commissioning Group (used to be NHS Trust) and they will send you a paper list (possibly by messenger pigeon). However, by the time changing a GP is on the agenda most people have already obtained the name of a GP or surgery to which they want to switch.

3. GP Home visits. This service has to be available from a surgery but it is the GP’s call on whether you can access it, ie whether it is appropriate in your circumstances. Most GP’s make this service available either through rota or locum. Some employ nurses or paramedics which technically is a bit naughty but as long as the service is overseen by an on call doctor it might just as (if not more than) sufficient.

4. GP Second Opinions Once again, you can ask, but, you cannot insist. There is no automatic right to a second opinion. However, most GPs will consider your request seriously, if there is any doubt about their treatment or diagnosis they should allow a second opinion. This may well be with a different Doctor at the same practice though and you don’t have the right to choose who, unless you are asking for a private referral and paying out of your own pocket. If you are considering a private referral though and before you fork out, believe me when I say that, GP’s genuinely will, seek to help you, as an absolute priority. If the refusal is a flat one without reason, then you can of course change your GP. In these circumstances perhaps, that is possibly the best solution as no doubt the faith in your doctor has diminished. You are not trapped, nobody is, you can change.

Your Right to NHS Hospital Care. 5. Emergency Treatment Every medical emergency is one that should attract treatment, however, in the main, the nature of the emergency would dictate what the treatment should be and this is rarely going to be anything other than a swift triage and a referral on from Emergency services to elsewhere in the hospital. All Hospital treatment with the exception of Emergency care should flow up from a GP referral. At this point it is worth noting the NHS e-refferal process see https://www.nhs.uk/using-the-nhs/nhs-services/hospitals/nhs-e-referral-service/ for full details but where you have the option at the outset of venue or expert, the service will allow you to make informed decisions about your care as well as cancel or amend existing appointments. You will however need a booking reference number and in many cases this is the holdup in the first place. Always remember your GP is your greatest friend in managing your healthcare. S/he can bring more pressure to bear on the local hospital than you ever could.

6. Consultant Review. In most of Europe where private healthcare rules (ok), you obtain a preliminary or working diagnosis from your local medical centres doctors (in association with hospital ancillary services) and they will say to you “there you are – that’s what you have – you now need a specialist to look up your bum or whatever”. You can either pick the one they recommend, or you can thumb through the directories until you spot a consultant you like the look of, you can research his background, schools, training and look into his statistics. You can then make an appointment and arrange to have your records forwarded by your local medical centre. It of course costs a fortune but that is what your insurance policy premium is for, after all, why else would you choose to be a fat German businessman if not to throw around your teutonic weight and be spoken to as if you are a 19th century steel magnate. Here in good old Blighty. The situation in the NHS is not that different and some would argue, much better. Your GP will refer you to who s/he thinks an appropriate consultant (who will probably undertake the ancillary investigations himself). You can object and you have the right to refuse your GPs choice of a consultant if you wish, in fact, you can nominate your own if you want, as long as the consultant is an appropriate one clinically speaking and is within your trusts reach. You and your GP though, should agree on the referral, unless you have no preference. Take note however, if your GP thinks this is an urgent referral he will send you where you can get in first. If you object to this then that may result in a delay and that would be nobody’s fault but yours. There are some exceptions to this “choose who you want scenario” and it will not be a surprise that in emergency medicine you get the clinical “bod” whose next available. After all as the old joke goes, “nobody ever complained about a doctor whilst having a heart attack”. Exceptions exist differently across the country but you expect limited choices in mental health, cancer services and maternity teams. They are very underfunded, very strained and in almost every case superb. Getting a consultant second opinion is however, not an automatic right. In the first instance clarification by the consultant should be sought and a full written explanation of advice given. If this is still considered to be inappropriate by the patient then the GP must be consulted and a re-referral made. Again, the GP will consider the most appropriate consultant and again it should be noted that the referral letter will be marked “2nd Opinion” and that the new consultant will see the original consultants outcome and any test results published.

What about my Surgeon? Well here’s a turn up for the books, while there is some flexibility with regard to consultants with regard to surgery the waters are getting clearer and clearer. In the recent case of Kathleen Jones v Royal Devon and Exeter NHS Foundation Trust 2018, it would seem that the issue of patient choice has been adapted. Ms Jones had a significant spinal issue (non congenital) that resulted in a bulging disc. Ms Jones had the good luck to be seen by the renowned orthopedic surgeon “Mr Chan” she under Mr Chans expert care was counselled in and accepted that decompression surgery was the operation most likely to bring relief. At the point of operation she was informed however that the operation would not be performed by Mr Chan at all but by a Mr Sundaram. The Court accepted that Ms. Jones was at that point effectively corralled into accepting the new surgeon. Regrettably indeed for Ms Jones, the operation did not go well, in an interesting turn of evidence the Court did not hold Mr Sundaram to be negligent in the performance of the operation but did feel that the operation was only just within the boundaries of what was acceptable as a non negligent outcome. However, the claim did not fail, David Blunt QC sitting as Recorder accepted the view that the operation would have had a significantly lower risk profile had it been performed by Mr Chan. Following the position in Chester v Afshar (2004) UKHL 41 at (86) the Judge found that there exists the right of the patient to make an informed choice as whether and if so which and by whom the operation is performed.

Summary The whole process of patient choice is becoming liberalised. In line with attitudinal changes in our societies our expectation of care is not one that is limited by deference to office holders and ultimately patients will want to know that there care givers are ones that they would choose. The trend is set and there is no going back.

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