PRASIS Code of Practice 2017

Recurrent themes identified in the adverse events reported to PRASIS have led the Board to develop the following ‘Code of Practice’. This is commended for adoption by PRASIS members to reflect good practice and reduce the risk of adverse patient outcomes.

For the avoidance of doubt, this Code of Practice does not substitute the GMC Code of Conduct. Should any conflict arise, the GMC Code of Conduct shall take precedence.

Pre-operative assessment

As a responsible surgeon, you will:

Assume responsibility for a patient’s care
Ensure the patient’s suitability for the planned surgical procedure.
Ensure that the patient is made aware of all material risks associated with the planned surgical procedure so as to be in a position to make an informed decision to proceed (see further below).
Outline the anaesthetic options available to the patient for the procedure and if required facilitate involvement of an anaesthetist.
Consider referral to a clinical psychologist when a patient requesting cosmetic surgery appears to have unrealistic outcome expectations or an apparent disproportionate view of their appearance or where there is an existing mental health condition.
Write to the patient and their General Practitioner unless consent has been withheld, summarising the clinical position, the pros and cons of the proposed surgery, the realistic outcome from surgery, potential complications and required aftercare.
If the patient refuses to allow their GP to be informed of the proposed treatments despite being counselled about the benefits of doing so, a letter summarising the treatment options, realistic outcomes, potential side effects and complications and necessary aftercare should be sent directly to the patient. This letter should also set out the fact that consent to inform the GP had been withheld by the patient.
Recognise that you are under no obligation to undertake surgery or treatments, that you believe will be against a patient’s best interests.

Patients under 18 years of age

Assessment of patients under the age of 18 years demands particular care to ensure that the proposed treatment is in their best interests. You should understand that:

There is no obligation to operate on any patient unless failing to do so would be negligent.
Final decisions about cosmetic procedures in young patients can be deferred.
The law covering consent to treatment in patients under 18 can be complex, and you must be familiar with it and follow its requirements.
If you consider that any proposed procedure is not prudent, do not proceed even in the face of compelling emotional pressure that might be brought to bear – your first instincts on whether to continue will usually be correct.
Remember that those with parental responsibility could bring an action on behalf of the child and therefore you are exposed to both the young persons’ interpretation at any stage of the process and also those holding parental responsibility.
If in doubt seek advice from a colleague or from your PRASIS medico-legal advisor.
You must follow GMC guidance on providing care for children and young people at all times.

Consent

Good surgical practice requires surgeons to ensure that patients are properly consented. Poor, inappropriate or even a lack of consent is one of the most common causes of successful litigation. Consent should include the following:

Patients should:

Be provided with a full explanation of the proposed treatment, the risks and benefits including the range of possible outcomes, available alternatives and post-operative care - this should also be given in writing.
Be allowed the opportunity to address any concerns.
Be given time to reflect on their treatment options before committing to surgery (BAPRAS and the GMC recommend a ‘cooling off’ period of at least two weeks and we at PRASIS, believe this to be the absolute minimum, with four weeks considered more appropriate for cosmetic surgical procedures).
Sign and date the appropriate consent documentation.
Ensure that consent is obtained in a two-stage process with a cooling-off period of
at least two weeks between the stages to allow the patient to reflect on the decision prior to admission for surgery. Should this not be possible, good reasons should be recorded in the patient’s notes. Information on the procedure should be received at a different time to the signing of the consent form. (Professional Standards for Cosmetic Surgery, RCS, 2016).

However, the Board recognises that for some patients (e.g. emergencies and those requiring reconstructive surgery) treatment may have to be arranged more quickly. Only under exceptional circumstances should the surgeon meet the patient for the first time on the day of surgery.

Advertising

You will:

Ensure that all advertising of your services complies with Advertising Standards Authority and GMC guidelines.
Ensure that unrealistic claims about surgical outcomes are avoided.
Not make false claims regarding your qualifications and membership of professional bodies

Online Forums

You must:

Avoid deliberately or inadvertently developing the forum into an online free consultation.
Provide content for educational/informational purposes only. It is not a substitute for medical advice, diagnosis or treatment.
Comply with your legal and professional duties of confidence.
Refrain from being defamatory or making comments on the competence of other practitioners.
Take great care not to give a misrepresentation of your true experience and abilities.
Consider the advice you give in the same manner as speaking at a conference, where one is discussing personal preference or experience in a particular area or procedure, or a panel discussion where individual cases are presented for the panel’s opinion.

Financial arrangements

The GMC require all financial interests and conflicts of interest to be declared to patients.

This required you to:

Inform patients in writing of the full costs of treatment before seeking their consent to treatment.
Inform patients of any potential additional costs should revision surgery be required.
Declare any personal interest such as financial involvement/shares in private hospitals and provision of your plastic surgery services through a limited company or partnership.

Inducements

You will:

Not offer financial or other incentives - including the return of consultation fees – to patients to commit to treatments.

Continuity of care

Responsible surgeons oversee the pre-operative assessment, consent process, surgery and post-operative care. You will:

Delegate responsibilities to other surgeons or health care professionals only when satisfied that the individual concerned possesses the appropriate level of experience and expertise. Consider how you would demonstrate this if you were asked to do so in court.
Provide the patient’s GP with relevant details of the treatment provided and appropriate advice on postoperative care unless consent has been withheld.
Document any refusal by the patient, despite your advice, to the GP being informed.

Overseas Patients

For patients travelling from overseas your responsibilities do not end when the patient leaves the UK. You will take reasonable steps to:

Ensure appropriate length of post operative stay in the UK.
Ensure continuity of care on repatriation.

Remote Patients

For patients being treated at a distance from your home base you must:

Ensure appropriate post operative arrangements and cover by a suitably qualified colleague (see below).
Confirm any such arrangements in writing to all relevant parties.

Delegation

Clinical care may only be delegated to other doctors and health professionals who possess the requisite knowledge, skill and expertise to provide that care to a competent standard. Any care that a patient reasonably expects you to carry out must only be delegated with the explicit consent of the patient, which must be in writing whenever practicable.

Expertise and facilities

PRASIS members will:

Have the necessary expertise to complete a procedure to a reasonable standard and to manage foreseeable complications that may occur, or arrange referral to a suitably qualified colleague where necessary.
Ensure that the facilities, equipment and assistance are adequate to manage any complications that may occur during or after surgery.
Understand that PRASIS indemnity is solely in respect of the individual member’s personal acts and omissions
Understand that PRASIS indemnity does not normally provide any cover for colleagues or other health care professionals assisting them in a procedure or performing a procedure under the direction of the named surgeon.

WHO Checklist

The WHO checklist or a locally agreed equivalent is integral to current best practice. You will:

Complete the WHO checklist or a locally agreed equivalent prior to surgery
Where any form of medical device or prosthesis is to be used during surgery, confirm that the product type and size is appropriate and that it is in date.

Product Liability

Suppliers of implants or other medical devices are at risk of involvement in product liability issues. If you are part of a supply chain, you are required to hold adequate product liability insurance.

Aftercare and access to emergency advice and assistance

Informed consent includes understanding of any procedure and its sequelae including wound care, as well as any restriction upon activities and likely time off work. You will:

Ensure that the patient is made aware of the sequelae of a procedure and confirm this in writing.
Ensure that patients have immediate access, in the event of concerns or complications, to the operating surgeon or a suitably qualified deputy so that all potential problems can be addressed satisfactorily.

Clinical records

Adequate records of all patient contacts are of paramount importance in current clinical practice. You will:

Document any patient contacts in the patient’s clinical records with date, time and signature.
Obtain good quality pre operative photographs for patients undergoing any surgery related to their appearance.
Record details of all implants and other products used during a procedure in the clinical notes.
Include a record of all care provided by nursing and other staff, under the direction of and on behalf of the responsible surgeon.
Be registered under and comply with the Data Protection Act 1998.
Ensure that all data is processed fairly and kept securely to avoid loss, damage or inadvertent disclosure. Any loss or unauthorised disclosure of sensitive personal data should be reported to PRASIS immediately.

Complications and complaints

The GMC requires all registered medical practitioners to provide patients with a prompt, full and honest explanation where complications have occurred. You will:

Respond to complaints in this way and apologise when appropriate.
Understand that providing an explanation and apology, where appropriate, does not amount to an admission of liability if done correctly.
In all circumstances, seek advice from your PRASIS medico-legal advisor before responding directly to patients as an explanation with apology could be taken to constitute an admission if not worded correctly (especially if accompanied by a refund of fees).
Understand that liability is a legal matter and not an issue to be discussed by patients and clinicians.

Notification of claims and/or circumstances

The Indemnity Schemes arranged by PRASIS provide members with indemnity for costs and damages incurred in clinical negligence claims, through claims made insurance policies. You must report all circumstances which may reasonably be expected to give rise to a claim to the 24 hour Medico Legal Helpline, as soon as it is reasonably practicable. Your policy will also provide other covers such as Public Liability, and these claims should also be notified to the same helpline. Please refer to your policy documentation for full details of the policy cover, terms and conditions, which will also include details of the Medico Legal helpline that is applicable to your policy.

Failure to notify cases or to co-operate with the claims management team may jeopardise the indemnity available.

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