Examples of common Probity issues to reflect upon

The stressed underperforming colleague?

A doctor you work with is short tempered, looks tired and doesn't hold your gaze. You have heard that the doctor is going through an unpleasant separation, that they recently lost a younger sibling in an road traffic accident, and that dealing with the legalities of probate is taking months.

• How do you approach this type of situation?

The "burnt out" [or possibly lazy] underperforming colleague

The team has noticed that Dr XX starts late and leaves early. Sometimes Dr XX sounds irritated on the phone to patients. Dr XX doesn't appear to do much CPD either; and is often heard to make cynical remarks about patients and talks a lot about retirement.

• What actions might you take?

Other professionals: simple errors or criminality?

You are aware that the local/hospital pharmacy has made frequent dispensing errors recently - some have been potentially dangerous.

• What should you do?

You are disturbed to discover from a patient that one of your colleagues seems to have made a potentially fraudulent record in the clinical notes.  You realise that this is open to more than one interpretation and needs to be handled sensitively.

• Do you know what you are required to do?

You discover that one of the local pharmacies has been ordering repeat medication for patients, some of which the patients are no longer taking as you had discontinued them some months ago. The prescriptions were left on the practice computer list and have been signed off without being checked. On inspection, it seems that one of these patients died last year.

• How should you proceed?

Stock order forms

A GP colleague frequently orders antibiotics on stock order - when questioned he says he uses them for his children because he and his wife [she is also a GP] are too busy to take them to the doctor if they have a minor illness.

...

A colleague is ordering analgesia on stock order for his wife who has back pain. He says he doesn't want to bother the out-of-hours services.

...

A colleague orders tramadol and benzodiazepines for himself on stock order. He is awaiting surgery for a lumbar disc protrusion.

• How could you respond if confronted with one of these situations?

Giving testimony

A senior colleague is well known for his rather abrupt manner. One day you overhear him having a heated conversation with one of the nurses, in the course of which you hear him swear. Later you learn that the nurse has made a complaint against this colleague with a charge of bullying. Your senior colleague then comes to you, asking if you will support him as a character witness in the impending hearing.

• What issues must you consider?

Who should a doctor take on as a patient?

You work with a GP colleague whose close family are patients of the practice. You work in a rural area but there is another practice located three miles away.

...

Your yoga instructor wants to join your practice "because she likes to know her doctor".

...

A doctor in a suburban practice has registered himself as a patient of his own practice.

• What is GMC guidance about this?
• In what circumstances do you think is acceptable to register close family and friends as patients?
• What are the issues that arise for the GP, their medical colleagues and for the family or friends who are patients?

Substance abuse?

You are aware that a colleague is sometimes very moody.  Once you thought you could smell alcohol on his breath - but you were not certain.  Then one Friday evening you were coming back from a meal out and notice him in the street looking drunk.

• What would you do?

A young colleague likes to go "clubbing" a lot at weekends.  One Monday you think his pupils are unusually pinpoint.

• What issues does this raise and how should you proceed?

Insurance reports

A patient had a depressive episode, a single psychotic episode or a single seizure and doesn't want you to include any mention of this in an insurance report.

• How do you respond?

You are asked to complete a travel insurance claim.  The patient developed an axillary abscess infection and had to see a doctor whilst on holiday abroad.  He had one previously [4 years earlier] - which you mention in the report.  The patient phones the practice to leave a message.  He thinks that the first abscess is not relevant as it happened so long ago and asks if you could please leave it out of the report.

• How do you deal with this?

Relationship with drug reps / pharmaceutical industry

Mr AA is a drug rep in your golf club who frequently offers to buy you a drink when he sees you in the bar.  He asks if he can come and see you in your practice to "talk professionally".  He is captain elect of your golf club.

• How do you respond?

You are invited to join a trial of a new drug for osteoporosis - with financial inducements.

• What are the issues you should consider?
• How do you feel about drug company sponsoring of meetings?  Should you be wary?

Financial / income issues

You are under pressure from a partner to round down the recorded blood pressures of some patients because the practice is having difficulty meeting QOF targets.  She says "blood pressure is very variable anyway".

...

A partner suggests that you should use exception code more frequently because the practice is failing to meet QOF targets and so will lose money.

• How would you respond if you were a partner?
• How would you respond if you were a salaried employee of the partner in question?

A senior GP colleague is part owner of a local care home. You are aware that many of his patients are residents and you were told recently by an elderly patient that he had recommended the home to her.  It is not clear if this lady knows about your colleague's financial interest in the home.  It is a good care home but costs approximately £200 more per week than two neighbouring homes.

• What issues must you consider and what should you do?
• How would you act if you were to learn that the nursing home was not being run as well as previously, because patients complained to you their resident relatives were being poorly cared for?

Undue influence?

A local restaurant owner has joined your practice. His restaurant happens to be one of your local favourites.  The next time you go to eat there, he very obviously reduces your bill by £10.  When he comes to consult you he often brings a box of delicacies from the restaurant.  He has just mentioned that his mother is coming to stay with him from overseas for a few months.  He says she has many medical problems and he hopes that she will be able to get some good treatment whilst she is in the UK.  He asks if she can register as a patient with you.

• What issues does this raise?

One of the experienced receptionists suffers from recurrent urine infections.  You know this because she frequently asks you to see her as a temporary patient when she is symptomatic.  She says that Dr BB [your former colleague, now retired] had seen her in this way for years.  She is asking for antibiotics increasingly often - and says that she can never get an appointment with her own practice because they are always so busy.

• What should you do?

Criminal offences

Dr HH was hurrying to catch a ferry for the start of a family holiday in France.  It was a stressful journey with a very tight deadline and the children were fighting in the back of the car.  Dr HH didn't realise how fast she had been driving down the motorway until stopped by a police car.   As a result Dr HH has two points on the licence.

• Which criminal offences must a doctor report to the GMC?

Competence of colleagues

Dr KK is a locum doctor who provided maternity leave cover for several months has now left the region but as patients she saw come back for review, it has become apparent that she made some very unusual prescribing choices.  Some of her prescribing is so different from the norm you are concerned that it is bad practice.  You are aware that she worked as a hospital clinician for some years.

• What are your responsibilities to your patients, to the wider medical community and to other patients whom this doctor will see in the future and how should you proceed?

Self advertisement?  Conflict of interest?  Endorsement?

A part time GP colleague has trained in laser surgery treatment for minor skin lesions. He is keen to make use of his new skills but has been having difficulties finding local premises from which to run a private clinic. The district nurses have just vacated the large room they occupied, because they have moved to a neighbouring practice under "cluster working". Your colleague asks if he can rent this room and run his clinic from there. He also asks if he can advertise in the practice leaflet and in the waiting room. He offers the partnership a small share of the profits in return.

• What issues of probity does this raise?

Dr MM is a senior GP partner, whose husband used to run a private physiotherapy and sports medicine clinic.  Dr MM has just reduced her sessions prior to retirement in a few years and her husband would like a less stressful life and wishes to work simply as a part time single handed physiotherapy practitioner. They are proposing that he uses a consulting room in the practice to see his private patients and have suggested that he uses his wife's room on the days that Dr MM is not consulting. The medical centre is jointly owned by the partners and Dr MM has a disproportionately large stake in the property. You have heard second hand reports [through patients] that Dr MM's husband had a very brusque manner when he ran his physiotherapy clinic and was actually asked to leave because his colleagues could not work with him.

• What probity issues does this request raise for you?

Your neighbour has recently trained as a psychotherapist. She is setting up in practice and has brought round some business cards and flyers for her services, which she has asked you to make available in your clinic. She asks you directly if you could refer suitable patients to her.

• What would you do?