Doubling up

The next instalment of the clinical scenarios is now available. It’s certainly a very common occurrence and adds pressure onto any surgery. How do you manage this?

Doubling up

A patient well known to you with multiple health problems has recently got married. Her new husband registers with your practice. He also has multiple real health problems. Every time the wife comes to see you, the husband brings up his own health problems and wants to discuss them with you. He always states that his problems are urgent but never makes his own appointment. You have asked him several times to make an appointment for himself rather than discuss his problems in his wife’s appointment but this behaviour is persisting. They are frequent visitors to the surgery and always make you run late.

Suggested points for discussion:

  • Is it appropriate for the husband to discuss his own health problems in his wife’s appointments?
  • How might you manage this situation?

Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:

Link to latest (February 2018) forum discussion within the OLE:



Prescribing and prescription charges.

This month’s clinical scenario is now available for you to consider regarding a situation which I have definitely experienced. Also with regards to mebendazole for treatment of worms in families. Following these, I have fairly clear plans for how I now manage such situations but look forward to seeing if mine are similar to yours.

Prescribing and prescription charges
You are a GP working in an inner city practice in an area of significant socio-economic deprivation. You see a mother and 3-year-old son who has an itchy rash all over his body. The rash is in his finger creases as well as all over his abdomen. You suspect a diagnosis of scabies and treat with permethrin. You recommend treating the rest of the family which on further questioning consists of mother and father, two older siblings aged 17 and 18 years and the patients grandmother who is 59 years old and lives with them.
When explaining the need to treat the whole family to the patients mother, she asks you to prescribe all the treatment in the child’s name as the mother wishes to avoid paying the prescription charge. When you explain you cannot do this, the patient’s mother becomes angry, threatens to complain and states that the rest of the family will go untreated unless you prescribe as she requests.
Suggested points for discussion:
  • What would you do in this situation?
  • Is it legal to do as the patient’s mother asks?
  • Do you have a duty of care to ensure the other family members are treated?
  • What other options are available to help the patient’s family?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (February 2018) forum discussion within the OLE:

Gifts; more trouble than they’re worth?

Having just had Christmas, I would be fibbing if I didn’t look forward to the odd box of chocolates and bottle of wine from a patient. Although I am aware that I probably received more as a trainee than I do now! I am blaming this on working fewer clinical sessions now, but I am also aware that I don’t have as much time to give to patients. However, should I assess my value as a good GP on the number of Christmas gifts I receive? Probably not.
The scenario below however, is a little more than a box of chocolates. I think I would feel very awkward, but see what you think….and don’t forget to add your comments.
Practice donations
A very grateful patient comes in to see you following a successful procedure to remove an early bowel cancer that you detected. As he gets up to leave, he thrusts a thank you card into your hand. When you open it after he has left, you find £400 in cash enclosed in the card.
Suggested points for discussion:
  • Are there any rules about accepting patient gifts?


  • How might you manage this situation?


Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (December 2017) forum discussion within the OLE:

Prostate cancer screening. Clinical scenario

This month’s clinical scenario is now available for discussion. This can be included with your reflection to your portfolio/CPD and you can see what others have commented on previously.
Prostate cancer screening
An 89-year-old man comes in to see you to ask for a prostate specific antigen (PSA) test. He is very fit and well for his age and has no urinary symptoms. He asks you why there is no national prostate cancer screening programme when there is a breast cancer screening programme. He recently watched a television programme which had concluded that thousands of men’s lives could be saved if there was a national screening programme. He thinks the lack of a screening programme is very sexist.
Suggested points for discussion:


  • Is it true that thousands of men’s lives could be saved if there was a national prostate cancer screening programme?
  • What are the possible harms that could be caused by PSA screening?
  • If you were this man, would you ask for a routine PSA test?


Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (December 2017) forum discussion within the OLE:

Refusal of treatment

In case you haven’t seen already we are really keen to receive your thoughts and suggestions on InnovAiT. What do you like now and how can we make it better for you? All AiTs please do take a couple of minutes to complete the survey available here
Last month you shared some very interesting comments and thoughts on the clinical scenario regarding dental pain. There was general consensus that the patient needs to see a dentist but that assessment should be considered as to how unwell the patient is (?septic ?admit), if there is a sinister underlying cause (refer to maxfax/consider immunosuppression). There is clear BMA guidance as to how we should manage this situation which can be found in the feedback for last month’s scenario here
Below is this month’s Clinical Scenario regarding refusal of treatment. Let us know how you would manage this situation.
Mr Halliday has severe asthma. He lives alone but has a home carer daily. His daughter is his next of kin and lives nearby. He has recently been admitted to hospital with a severe exacerbation of his asthma. The discharge summary states that Mr Halliday has poor understanding of his asthma which was putting him at significant risk of further severe exacerbations. The following week you receive a request from Mr Halliday’s carer for an urgent home visit as ‘his breathing is bad again’. 
When you arrive he is clearly struggling with his breathing but refuses to see you, speak to you or be examined. He has thrown his inhalers in the dustbin and says that he’d ‘be better off dead’. You try to tell him that without treatment he could die from his asthma but this makes no difference. On returning to the surgery you call the mental health crisis team to ask their advice about how to manage this situation. They agree to go to see him to assess his capacity to refuse admission but, when they arrive at the house, his daughter answers the door and says that mental health assessment is not required. She sends the crisis team away without seeing Mr Halliday.

Suggested points for discussion
Could you have admitted Mr Halliday to hospital in his ‘best interest’ when you saw him, even though he is refusing admission?
How might you manage this situation?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (November 2017) forum discussion within the OLE:

Benzodiazepine dependence


Benzodiazepine dependence is an increasingly recognised and often iatrogenic problem. Where does the balance lie between ‘safe’ use and dependence? How do you manage your elderly patients who have been on their nightly diazepam for years and insist they can’t possibly manage without them? For newly qualified GPs or registrars this can be even harder when you are often following in the footsteps of well established GPs who may have had a different prescribing pattern. Do you have a practice policy or is there variation between the GPs in your surgery? Does the reason for request alter your thoughts? Fear of flying or the dentist which may only require a short prescription, or insomnia which may be an ongoing problem. If you are already running late, is the lengthy discussion to encourage the patient not to use them going to take too long?

Lots of doctors have different opinions – some can be hardline and almost never prescribe, others may comfortably issue and repeat them. Do you know where your prescribing trend sits? If you are preparing for the CSA, are you happy with how you would manage a request?

In this month’s InnovAiT, there is a great article by Dr Ayla Cosh and Dr Helen Carslaw going into detail about these issues and how to support withdrawal as well as some great links to other resources.


Dental Infections – Clinical Scenario

This month’s Clinical Scenario from the RCGP forum is regarding dental infections. There is a huge amount of discussion from Indemnity organisations and social media groups about how these should (or shouldn’t) be handled. Are you clear what you would do?

Dental Abscess
A 25-year-old patient presents to the GP with a history of toothache. The pain has developed over several days. He says he does not have a dentist and has not needed to see a dentist for several years. He is managing to eat and drink normally and the pain is relieved with simple painkillers. There is no history of fever or systemic illness. He is insistent on having antibiotics from the doctor. He is sure this is appropriate as he had a similar bout that responded well to antibiotics from another doctor seen out of hours. After careful assessment, the GP feels antibiotics are not warranted and forwards him to the emergency dental services.
The GP subsequently receives a complaint from the patient who went on to develop a large dental abscess requiring surgical drainage. He complains that the GP failed to manage his dental infection correctly and should have given him antibiotics.
Suggested points for discussion:
  • What is the differential diagnosis?
  • What are the indications for prescribing antibiotics for dental pain?
  • What safety-netting advice is important to document?
  • What is your local referral pathway for emergency dental issues?
Link to RCGP Forums: InnovAiT Clinical Scenarios course within the OLE:
Link to latest (October 2017) forum discussion within the OLE:

Enfranchising our patients

Blog kindly submitted by Dr Jonathan Mills and Dr Unniparambath Prabhakaran.

With the recently held (and somewhat unexpected) general election in June, this provided an opportunity for us to reflect that as GPs, how we encourage our patients to exercise their democratic rights, and are we aware just who can vote?

Whilst voting can be straightforward for many people who have registered, as GPs we should be mindful of those who are disenfranchised by the very nature of difficulty getting to the polling booth or posting a vote. This is particularly the case for those in care homes, hospital and psychiatric units, where physical health problems restrict participation, or the locked nature of some of the wards serves as a barrier to exercising the right to vote. In the 2010 General Election, psychiatric inpatients were half as likely to register to vote. If registered, they were again half as likely to vote compared to the general population (McIntyre et al., 2012). The majority of those unregistered were not aware of their eligibility to vote or the registration process.

Historically, inpatients in psychiatric settings were disenfranchised in UK general elections as ‘lunatics’ and ‘idiots’ under the Representation of the People Act 1949, before the electoral Administration Act (2006) granted psychiatric inpatients a right to vote whether they were informally admitted or detained under the civil sections of the Mental Health Act 1983 (MHA). Thus psychiatric patients have a right to vote personally, or by proxy, and should be encouraged to register to vote and exercise that right should they choose. For clarity, patients who are sectioned under civil sections of the MHA (this also includes prisoners remanded to hospital under the MHA on Sections 35, 36 or 48) are entitled to vote (Royal College of Psychiatrists, 2015). However, prisoners detained after conviction of a criminal offence who are ordered to hospital be the courts and those who have impaired capacity (which includes dementia) do not in themselves demonstrate legal incapacity to vote, and these individuals should be supported if they intend to register and vote (Royal College of Psychiatrists, 2015).

A GP may have patients in the community under care of psychiatric teams, subject to mental health legislation (such as Community Treatment Orders) who are also entitled to vote, despite restrictions to their liberty such orders may pose.

Similarly, patients who are homeless can make a ‘declaration of local connection’ should they spend a significant period of time at a particular address or location. Those in residential and nursing homes may lack the physical ability to go to a polling station, or even to physically mark a ballot paper, but again this should not be a bar to choosing their representatives. Care homes should be encouraged to help residents register and vote. Where someone is unable to vote but wishes to do so, remind them they can nominate a proxy to enable them. As GPs, we work under the premise that adults have capacity until proven otherwise, we should also work under the assumption that patients have capacity to register and vote.

McIntyre J, Yelamanchili V, Naz S, Khwaja M, Clarke M. Uptake and knowledge of voting rights by adult in-patients during the 2010 UK general election. The Psychiatrist 2012; 36: 126-130

Royal College of Psychiatrists, Voting rights for mental health patients, (2015), available via Last accessed 18/7/2017


Working abroad

Here is this month’s Clinical Scenario from RCGP Learning in conjunction with Several of my peers from VTS training have either worked or moved permanently abroad since qualifying and this seems to be the case nationally. The pull of family needs here and the appeal of working abroad is a very real one – let us know your thoughts on the comments page which you can access from this link

Dr Anderson has just completed his GP training in the UK and has been doing some locum work. He has seen an advertisement for a GP post in rural New Zealand and thinks that he might apply. However, his mother has a long-term illness and he is worried that, if he does go to work abroad, he might not be able to return to work in the UK as a GP should his mother deteriorate and need his help.

Suggested points for discussion

  • What are the rules about UK-trained doctors returning to work in the UK after some time abroad?
  • How might Dr Anderson maintain his right to practise in the UK whilst working abroad?
  • Would these rules be different if Dr Anderson was trained in New Zealand and wanted to come to work in the UK?
  • What other factors might influence Dr Anderson’s decision?


Difficult decisions

Did you see the brilliant August Special Edition on Difficult Decisions? In case you missed it, there is a wealth of discussion around many different difficult decisions which regularly affect us.

I was really interested in the article ‘The ethics of GP commissioning’ by @gentlemedic, a Clinical Lecturer from Oxford University and Dr Cox, GP with special interest in Ethics and medico-legal work. I work for our local CCG and have to advise with a much wider population view so was particularly interested in this discussion, but also the ethics around the decisions we make to manage the care of our individual patients or practice population.

The great @DuncanShrew writes about the impact on us, of all the decisions that we have to make which was certainly a message which rang true with me. I have heard it said that as GPs we make a decision every 10-20 seconds  – whether to pursue that mention by a patient of chest pain in amongst the other plethora of symptoms, or in amongst a list of 80 medicines management is it ok to re-issue this medication, or whether to read the urgent screen message whilst the patient is in with us or wait until they have left. I remember on more than one occasion of getting home from a long day, my husband has asked if I would like a cup of tea and I have genuinely struggled to answer. Decision fatigue is very real for me.

The article ‘The psychology of uncertainty in difficult decisions‘ is a fascinating closer look at our reactions to the horribly uncomfortable moments of just not knowing what to do easily referred to as ‘WDYDWYDKWTD moments’ (What do you do when you don’t know what to do). The fear that if only a better doctor was seeing this patient or looking at these results because they would obviously know what to do. I recognise that I had these a lot as a trainee, and in no way do I now know all the answers, but having strategies for how to manage the situation is so very helpful. I couldn’t really understand this when my supervisor told me to learn how to manage the situation, it felt like a cop out, that actually we should just work harder to know all the answers. The realisation that we can’t and that our role is also to risk assess is both helpful and daunting. This article is a good opportunity to consider why we feel the way we do in those WDYDWYDKWTD moments. The following article then considers sharing this uncertainty with our patients.

There are also lots of shorter scenarios posing difficult decisions which are produced in partnership with RCGP and with the opportunity to post your thoughts in the discussion afterwards. These are available at