Effects of the civil procedure rules on clinical negligence claims.

The frequency with which clinicians can expect to face allegations of clinical negligence and court proceedings related to those allegations is likely to increase in coming years. The processes of investigation and defence have been modified by the introduction of the Civil Procedure Rules in 1999. This review outlines these developments and emphasises the need for speedy and comprehensive responses by doctors involved in such procedures.

The NHS complaints system.

This paper reviews the methods by which complaints are currently handled within the NHS.

Towards better informed consent in endoscopy: a study of information and consent processes in gastroscopy and flexible sigmoidoscopy.

OBJECTIVE: To determine the level of knowledge achieved by patients who have read a simple information sheet on gastroscopy and flexible sigmoidoscopy, and to determine the levels of information required by patients and solicitors specializing in clinical negligence. DESIGN: Self-administered questionnaires were sent to 516 patients in Leicester and 79 solicitors specializing in clinical negligence in England and Wales. The main objective outcome measures were the correct scores measured in a simple test of the content of information sheets about gastroscopy and flexible sigmoidoscopy. Other scores were based on the opinions of patients and solicitors on the type of information patients should receive and the levels of risk about which they should be informed. RESULTS: Of the clinical negligence specialists, 75%, compared with 44% of patients, felt that consent to procedures should be obtained 2 weeks before the test. In addition, 86% of solicitors felt that patients needed to be told about tests on at least two occasions and favoured booklets and videos. Both 48% of solicitors and 38% of patients felt that patients should be told of very uncommon risks, with 16% of clinical negligence specialists expecting patients to be told of risks of 1 in 1,000,000. The majority of patients (98%) and solicitors (95%) felt that patients should be formally tested as to whether they understand what they are told in the consent process. In an initial study of an information leaflet, South Asian patients had significantly poorer scores than English patients on formal testing of their knowledge of the leaflet's content. The poorest response (61% correct) was to a question including the word 'indigestion', which had been omitted from the information leaflet. Its inclusion led to a significant increase in the number answering the question correctly (96%). The positioning of a word in the list of reasons for doing the test was also important. In the flexible sigmoidoscopy leaflet, the word 'anaemia' was placed in the middle of a list of reasons for doing the test; only 85% answered the question correctly. In the sample of patients who received the modified gastroscopy leaflet, recall at 6 months was significantly impaired with most loss of memory being related to the purpose of the test. CONCLUSIONS: Consent needs to be supported by easy-to-read information and the patients' understanding needs to be formally tested. Important concepts must be included in this information as well as any uncommon risks of the procedure. In order to ensure that the information can be understood, the text should be reviewed by an experienced educationalist. If the text is to be used in a multicultural setting, it is important to ensure that patients for whom English is not their first language can easily understand it. The movement away from 'informed consent' towards an 'informed decision' process should facilitate these improvements.

Screening: the legal view.

Screening has become central to the effective prevention of several diseases, but implementation suffers from difficulties with targeting and rates of compliance. Such issues are also complicated by the need to consider legal provisions regarding confidentiality of patients and other human rights issues. Screening has been an inexact science in relation to, e.g., faecal occult blood testing for colorectal cancer, false positive and false negative tests for HIV, and there have been inadequate quality controls in breast cancer screening programmes. The public need to be made aware of what the screening programmes really offer, balanced against the expectations they may have. There needs to be a clearer understanding of the nature of the contractual and other legal rights of patients/consumers as against providers. A positive screening test may carry adverse consequences as well as benefits. It could alert an insurance company to a risk and lead to additional weighting or even outright rejection for life insurance policies. Job prospects may also be affected for employees. The method of informing patients in relation to screening and screening failure has already been considered by the courts. Realistic information about both screening and treatment efficiency needs to be offered to patients so that they can have a real understanding of what can and cannot be achieved by current science. The development of understanding of the human genome makes the need for clearer legislation in this are more urgent.

Questionnaires: the use and abuse of social survey methods in medical research.

We present a working review of survey methods based on market research technology. The structure of questionnaires, their distribution and analysis, are considered, together with techniques for increasing response rates.

Effective instructions for patients.

Information designed for patients aims to educate them. This means that the written word must be both read and understood. In whatever format patient information is presented it must influence patient behaviour and favourably affect compliance and morbidity if it is to be of value. The production of patient information should take account of the needs of the audience as well as the aims of the educators. Prototypes should be field tested to ensure that they are effective and that the material can be revised before general use. Patient information and its effect on the understanding of disease processes and management can be assessed by various standard techniques. Their effectiveness must ultimately be validated in randomised controlled trials.

Survey of the attitude of medical and nursing libraries to information literature for patients with gastrointestinal diseases.

Senior staff in libraries at 281 medical schools, postgraduate institutions, schools of nursing and postgraduate medical centres were approached. They were asked to complete a detailed questionnaire on the availability of patient-orientated information and the nature of access by other health care professionals, patients and the public to their facilities. A total of 252 replies was received (response rate 90%). Medical and nursing schools tended to discriminate against each other's staff. Discrimination against patients was more widespread with less than 30% of libraries open to them. This was reflected in the lack of patient information such as booklets and videos. Less than 10% of libraries provided such information. Libraries in schools of nursing were significantly better in the provision of information about self-help groups. Overall there were limited interest in the provision of any service to patients or the general public.

An information booklet for employers on inflammatory bowel disease: an evaluation by patients.

Forty-eight patients with Crohn's disease were offered an educational booklet about inflammatory bowel disease directed at employers. They were asked to assess its value and the best method of distribution. Forty-eight per cent agreed to take part in the study and, of these, 74% completed the project. Although the book was considered valuable, and most patients believed it should be made available to their line managers, distribution was considered best left in the hands of doctors and self-help groups.

Practice nurses and chronic diseases of the gastrointestinal tract.

The potential value of nurse-based counselling of patients with chronic gastrointestinal disorders was investigated through a postal questionnaire survey of practice nurses in Leicestershire. The results suggest there is little prospect of developing practice-based counselling service in gastroenterology.

Perceived discrimination in education and employment by people with Crohn's disease: a case control study of educational achievement and employment.

Eighty three patients in whom the diagnosis of Crohn's disease had been made before the age of 40 years and who had been resident in the city of Cardiff were asked to complete a detailed questionnaire about their educational and employment experiences. Responses were obtained from 58 patients (response rate = 70%), 23 buddy controls, and 27 community controls. The mean (SD) age of patients at the time of the survey was 31 (5) years. Twenty four of the patients were diagnosed before leaving secondary education, at a mean age of 17 years. They had lost significantly more days' schooling than controls (chi 2 = 14.3 p less than 0.001) but had achieved similar academic success as measured by examination passes and attendance at tertiary institutes of education. Similar numbers of patients and controls were employed at the time of the survey, although significantly more patients had experienced long term unemployment (z = 2.6 p less than 0.01). As a result of their experiences up to 30% actively concealed their illness from employers.

Post registration training in gastroenterology for nurses.

This article is a review of the prospects for a specialised European training programme for nurses in gastroenterology. It discusses the possible integration of training in endoscopy and stoma therapy together with conventional nursing of acute gastrointestinal emergencies and the care of patients with chronic intestinal conditions. Despite the existence of a number of interested bodies, at present no such courses exist. If they are developed they should lead to an internationally recognised diploma of gastrointestinal nursing. Training in counselling techniques, terminal care and research methodology, together with computing techniques need to be incorporated in each course. The future of such nurses will be in non-academic hospitals, where they will have a role in the follow-up and management of patients.