Page Section: Centre Content Column

Getting the best from your health or disability service

Cataract surgery: availability of public care

Having a baby - your right to quality maternity care

Communication services for people with speaking and hearing impairments

Communication services for people with speech and hearing impairments (plain language version)

What do I need to know about "informed consent"?

Receiving treatment from alternative health care providers

Test results: is no news good news?

Test results: is no news good news? (plain language version)

Tips for talking with your doctor

Tips for talking with your doctor (plain language version)

Waiting to be seen in accident and medical clinics

 

Cataract surgery: availability of public care

In 2003-04, 8063 cataract operations were carried out in publicly funded facilities, and increased funding recently made available will provide for an increase in operations for up to 12,000 people over the next three years. Thousands more people with cataracts are not eligible for publicly funded surgery (Christchurch Press, 4 May 2005). Each District Health Board has its own funding allocation and will decide which consumers qualify for publicly funded care.

How will consumers know if they qualify for publicly funded treatment, and how long will they have to wait? The current policy is intended to provide certainty to consumers that if they qualify for treatment, they will receive it within six months.

Consumers will be referred by their doctors to ophthalmologists, who have responsibility to appropriately assess them to establish priority for publicly funded surgery. This is done using a national standard assessment tool, the National Clinic Priority Assessment Criteria (CPAC) for Cataract Surgery, which scores sharpness of vision, severity of visual impairment and the impact of other clinical conditions, as well as the ability to work, give care, live independently and any other disability. Ophthalmologists should advise consumers of their priority score, which will dictate whether they are offered surgery in the public system.

Each District Health Board (DHB) will decide its capacity to offer treatment according to the funding it has available, within the timeframe of six months.  In each case, the DHB will determine, based on the CPAC score, whether the consumer qualifies for surgery, and notify him or her accordingly. Some consumers may be classified for reassessment in six months' time; the remainder will be referred back to their general practitioner.

Consumers whose scores do not qualify them for surgery in the public system, and who have the financial means to do so, may wish to consider paying for cataract surgery through the private system, where they are likely to receive it within a few weeks.

Consumers who are seeking cataract surgery have a right to all the information that they might need to assist them with understanding how the system works, and any options they may have if they do not qualify for publicly funded surgery. It is the ophthalmologist's responsibility to give them the relevant information available, and answer their questions, including questions about how to get a second opinion, if they want it.

Information consumers should receive includes:

• information about CPAC Assessments and the points score
• an explanation of the way the points system dictates which consumers qualify for cataract surgery in the public system
• the way in which the Ministry policy is implemented in their DHB
• an explanation that consumers who do not qualify for publicly funded treatment may consider paying for treatment through the private system
• the likely delay and cost involved in surgery in a private hospital.

If a consumer is advised to proceed with cataract surgery, he or she is entitled to take time to consider the decision. Consumers must give written consent to the surgery and have a right to all the information they need in order to make the decision. Information about the surgery should include the expected benefits, risks and side effects. The ophthalmologist should provide written material for consumers to consider at home, especially if they have received eye drops that distort their vision, or are not wearing their glasses and cannot read the information.

Consumers' rights to receive all relevant information, including a written summary if requested, and the time to make an informed decision about treatment, are covered by Rights 6 and 7 of the Code of Health and Disability Services Consumers' Rights.

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Having a baby - your right to quality maternity care

Depending on the circumstances of your pregnancy, labour and delivery, you may have more than one provider involved in your care when you have a baby. Under the Code of Health and Disability Services Consumers' Rights, you have the right to co-operation amongst these providers to ensure you receive a quality service.

Lead Maternity Carer (LMC)
In New Zealand you are able to choose who you want to organise your care and to look after you when you have your baby. This person is called your Lead Maternity Carer (LMC) and will provide a comprehensive maternity service during your pregnancy, delivery and up until four weeks following the birth. This person will be responsible for organising the care you require, ordering and acting on any tests, and arranging any referrals or input from other health professionals. Your LMC may be a midwife, general practitioner or specialist obstetrician. The LMC discusses and plans your care in partnership with you.

A midwife is a qualified health care professional who has successfully completed a midwifery degree and is registered with the New Zealand Midwifery Council. Some midwives are self-employed, others are employed by a District Health Board (sometimes referred to as hospital midwives) or private maternity services. All midwives must provide care to a specified standard agreed by their professional body (the New Zealand College of Midwives), the Midwifery Council, and the Ministry of Health (via funding arrangements). The same standards apply to medical professionals.

The majority of women in New Zealand choose a midwife as their LMC. Some women choose a general practitioner or an obstetric specialist obstetrician. When the LMC is a doctor, you will also require the support of a midwife during labour, delivery and after the baby is born. Midwifery support is included when you register with your LMC.

The objective of the LMC approach is to have one person responsible for organising and coordinating your care and to provide the majority of your care as far as possible. All LMCs will be involved in your care during pregnancy and plan to attend your birth. You can get information and guidance about choosing your LMC, including any charges that may apply, from the Health Education section of the Ministry of Health, the Maternity Services Consumer Council or the NZ College of Midwives.

Backup arrangements
You can expect your LMC to tell you about the arrangements for your care if your LMC is not available. For instance, during pregnancy, a midwife may not be available for a scheduled visit and may recommend a colleague to take responsibility for your care temporarily. If an LMC is unable to attend the birth, they are responsible for organising a backup practitioner and ensuring you are well aware of this arrangement. If you are having your baby in a hospital, it may be necessary for your care to be covered by a backup midwife - either another independent midwife or a hospital midwife.

Transfer of care
A midwife LMC has primary responsibility for your care unless and until she transfers that responsibility in circumstances where you or your baby require ongoing medical care. Decisions about a transfer of care are made following discussions that involve you. Transfer of care may happen for a variety of reasons. In the case of complications or complex maternity needs, your LMC may recommend a consultation with a specialist such as an obstetrician, obstetric physician or other physician, or an anaesthetist. This may be for a single consultation or a series of visits. In some cases the LMC may be recommended to transfer your care to a specialist. The transfer may be for part or all of your antenatal maternity care, depending on your condition and the condition of the baby - for example, transfer of care to a specialist obstetrician in hospital for a Caesarean delivery.

Maintaining quality and consistency of care
In any transfer of care, you have the right to 'seamless' services so that you receive a consistent appropriate standard of care. Under the Code of Rights, all providers have a responsibility to cooperate with each other to provide quality and continuity of service. Where a transfer occurs, there needs to be agreement and mutual understanding of when and to whom responsibility for your care has been transferred.

In conclusion
You can expect to receive quality services from all maternity practitioners, including when care is transferred from one practitioner to another. It must be clearly understood by all parties involved who has overall responsibility for your care at any given time, and the point at which responsibility for your care is transferred back to your LMC. This information must be communicated clearly to everyone, and must be recorded in your clinical notes.

There must never be any doubt or confusion as to who has responsibility for any aspect of your care at any time, or who to contact when you require information, care or assistance.

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Communication services for people with speaking and hearing impairments

Systems for communication

The New Zealand Internet Relay (NZIR) is a means of telecommunication for people who are deaf, hard of hearing, deaf-blind or speech-impaired.

Callers use their PC or laptop to establish an internet connection with a relay assistant, and type their message to the other party. The relay assistant reads aloud the typed message to the other party, then types the verbal response.

This service is available at all times; there is no call surcharge, and local and national calls are free. Chargeable calls, such as those to mobile phones or overseas locations, can be made if the caller has previously registered with NZ Relay.

Registration for this service is by telephone (0800 4 713 713, TTY; 0800 4 715 715, voice) or by a registration form that can be downloaded from the New Zealand Relay website (www.nzrelay.co.nz).

The text telephone (TTY) is a device that lets people who are hard of hearing, deaf or speech-impaired communicate by typing messages back and forth to one another, rather than using an assistant to relay the messages. A TTY combines a telephone handset (which is set onto special acoustic cups), a keyboard and a text display.

Messages typed using the keyboard are sent over the telephone line (not the internet, as with NZIR) and appear on the text display of the person you have called. A TTY is required at both ends of the conversation. Information about TTY equipment can be obtained from the New Zealand Relay website.

HDC has technology to receive complaints by TTY and relay services

If you want to make a complaint about the quality of service you have received from the provider of a health or disability service, but have an impairment that makes using the telephone difficult, you can reach staff at the office of the Health and Disability Commissioner using either the New Zealand Internet Relay (NZIR) or the text telephone (TTY), as well as fax, email or letter.

The contact number for calling HDC via TTY is 09 373 1060. It is also possible to contact HDC using the internet via NZIR.

Calls are private and confidential, and material is erased as soon as the call is terminated, unless you request a copy for your own records.

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Communication services for people with speech and hearing impairment

(plain language version)

The New Zealand Relay (NZR) helps people who are deaf, hard of hearing, deaf-blind or speech-impaired to talk with other people. There are all kinds of ways to speak with others such as:

• Internet Relay;
• Textphone (TTY);
• Voice Carry Over (VCO);
• Hearing Carry Over (HCO);
• Speech To Speech (STS);

and more.

This service is open at all times. The service is free except to mobile phones or overseas countries. You can call mobile phones or overseas countries if you have signed up with NZ Relay for a calling card.

To sign up for this service you can:

• telephone 0800 4 713 713, TTY;
• telephone 0800 4 715 715, voice or
• download a registration form from the New Zealand Relay website, www.nzrelay.co.nz.

Further information on how each of the services works and the equipment required can be found on the New Zealand Relay website, www.nzrelay.co.nz.

Calls made through relay service are private and confidential, and material is destroyed as soon as the call is ended, unless you ask for a copy for your own records.

If you want to make a complaint about the quality of service you have received from the provider of a health or disability service, but you have an impairment that makes it hard for you to use the telephone, you can get in touch with staff at the office of the Health and Disability Commissioner (HDC) using any of the New Zealand Relay services or by fax, email or letter. If you wish to contact HDC using relay service, please dial 0800 4 713 713 (TTY) or 0800 4 715 715 (Voice). Ask the relay assistant to contact HDC on 0800 11 22 33 or 09 373 1060.

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What do I need to know about "informed consent"?

The recent media debate about the Meningococcal B Immunisation Programme has led to a response from the Ministry of Health (Sunday Star Times, 19 June 2005, A19) to clarify issues surrounding the prevalence of the disease in New Zealand and facts about the vaccine.

The debate raised questions about the nature of the information provided and prompted an assurance from the Ministry that it supports "informed consent".

The concept of informed consent is central to most health procedures. It is a prerequisite to any intervention, including screening, testing, vaccination and treatment. It means that when a consumer consents - or agrees - to a health procedure, he or she has made his or her own decision about whether to undergo that procedure.

Even when the decision is based on the provider's recommendation, the consumer actively makes the decision, rather than simply going along with the provider's recommendations. Clearly, in order to be able to agree to a procedure, a consumer must have all the information necessary to enable him or her to make that decision.

Information
A consumer is entitled to receive information about his or her condition, the options for treatment, and the anticipated outcome of each treatment option. This includes any associated physical, emotional, mental, social or sexual outcomes, expected risks and side effects of the treatment, the time frame in which these may occur, and any steps that can be taken to minimise them.

Where relevant, ongoing implications of the procedure need to be discussed. The option of not agreeing to undergo the procedure, and the outcome of this option, should also be explained.

If the provider recommends a particular option, he or she should give the reasons for the recommendation. The information provided should take into consideration the consumer's individual circumstances, such as personal and family history, that may influence the treatment choices or outcomes.

All viable options should be offered, not only those available through the publicly funded health system, and the cost of each option should be explained.

Consumers may also wish to consider complementary or alternative therapies, or services from providers outside conventional health services. Where a provider is not knowledgeable about such options, he or she should inform the consumer where to find the information.

In the case of vaccinations, consumers (or parents where young children are involved) can expect to be provided with information about the potential benefits, risks and side effects, along with relevant information about controversial areas and concerns about vaccination. If a child has previously experienced an adverse reaction to a vaccine, information provided will need to address this specifically.

Communication
Many problems of consent arise from poor communication. Consumers are entitled to "effective communication" - this means discussions should be conducted and questions answered in a form and language that enables the consumer to understand the information provided. Where necessary and reasonably practicable, this includes the services of a competent interpreter.

It may also involve using culturally appropriate methods of communication, plain language rather than medical jargon, written or visual explanations, and diagrams or videos.

The involvement of family, whanau or other support persons may assist understanding and provide support for people who are less confident about asking questions.

Effective communication depends not only on what information is requested and provided, but also on the manner in which the discussion is conducted. It is important that consumers are shown respect, feel comfortable about asking questions, and are given sufficient time to do so. Consumers are also entitled to receive, on request, a written summary of the information provided, in a form that enables the consumer to understand the information provided. Consumers must be given adequate time to consider the information and the available options, before making a decision.

Giving consent
Apart from exceptional situations (such as provision of life-saving treatment in an emergency, or when a consumer does not have the mental capacity to consent on his or her own behalf), the consumer's consent is always required before services can be provided. Every consumer has the right to refuse to undergo any treatment or procedure, and to change his or her mind and withdraw consent to services at any time, even if those services are already under way. There are special provisions in the Code to cover circumstances where a consumer does not have the mental capacity to give consent for him- or herself, such as circumstances involving children. In addition to parental consent, it is good practice for a provider to give an explanation to children, to gain their confidence and their willing participation.

For most tests and treatment, consumers can give consent verbally. However, even where verbal consent is adequate, some providers wisely record in the consumer's notes the fact that consent was obtained, as well as the information and options given.
For a general anaesthetic or where there is significant risk of adverse effects on the consumer, or where informed consent is required for participation in any research or experimental procedure, consent must be recorded in writing.

The rights underpinning the process of informed consent - the rights to effective communication, to be fully informed, and to give informed consent - are set out in the Code of Health and Disability Services Consumers' Rights (Rights 5, 6 and 7).

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Receiving treatment from alternative health care providers

When attending a provider of alternative health care services for the first time, a consumer may not know very much (if anything) about the treatment and procedures that are offered. In addition, different providers within the same discipline may use different practices. This can mean that when something occurs that the first-time consumer is not expecting or finds distressing, they may not know whether that practice is a valid part of the treatment or is outside the parameters of an acceptable procedure.

Complaints
Consumers who are unhappy with the treatment they have received from a natural health practitioner, or who feel that their rights have been breached, have the right to make a complaint about the services they have received. They can make the complaint directly to the provider, to a health and disability advocate from the Nationwide Advocacy Service, or to the Health and Disability Commissioner.

Complaints tend to fall into two broad camps: a lack of information or understanding of the procedure, or poor performance of the procedure.

Complaints to the Commissioner about alternative therapies often concern a lack of information about what the proposed treatment involved and why the techniques were being used. Some consumers report feeling uncomfortable during treatment because of the way they have been treated by the therapist. For example, there may have been inadequate covering of their body during the procedure, or inappropriate comments and questions of a personal (sometimes sexual) nature, or a lack of privacy while undressing. Some consumers have reported distress caused by inappropriate touching: practitioners working too close to the genital area, or touching the breast or nipple during massage.

To keep themselves safe, consumers need to:

• be aware of their rights to information and to give informed consent;
• choose the health practitioner carefully to ensure that they are going to a qualified and reputable provider.

Informed consent
The concept of informed consent is central to most health procedures, including procedures provided by alternative or natural health care providers, such as spiritual healers, iridologists, reflexologists and therapeutic masseurs. Providers of these services are subject to the responsibilities set out in the Code of Health and Disability Services Consumers' Rights, in the same way as are providers who follow traditional practices. The consumer's properly informed consent is needed before services can be provided.

Before consumers embark upon a session of treatment, they need to be very clear that they understand what is going to happen and why, and must have an opportunity to consent to the proposed treatment. Under the Code, the giving of informed consent is a process which embodies three essential elements:

• effective communication (Right 5);
• provision of all necessary information (Right 6); and
• the consumer's freely given consent (Right 7).

Information
Providers must voluntarily provide consumers with all the information that a reasonable person, in that consumer's circumstances, would expect to receive or need to receive. This includes an assessment of the expected risks, side effects, benefits and costs of each option, and information about the safety and efficacy of the proposed therapy.

In situations where a practitioner wishes to offer a treatment they believe to be effective, even though its efficacy is not yet proven according to scientific or evidenced-based principles, the provision of information is crucial. Health professionals have a duty to disclose any lack of scientific evidence for a proposed procedure, and give specific reasons for recommending it. The provider must give honest, accurate and complete answers to questions. Consumers should be given a choice of options so they don't feel pressured into receiving something they are not happy about.

Enough time must be allowed for the consumer to consider the information received before consenting to treatment. This may involve providing them with written information to take away to consider at home. Providers have a responsibility to provide a written summary of the information if the consumer requests it.

Communication
For communication to be effective, the consumer must feel comfortable about asking questions and feel that their queries are respected. The provider must be responsive to the needs, capacities and concerns of the individual consumer.

Consent
When a consumer is satisfied with the information received, and chooses to proceed with the treatment, they then give their consent. However, that consent may be withdrawn at any time, including during a procedure. Consumers should never be in a position where it is not possible for them to indicate to the provider that they wish to discontinue.

Standards of practice
Providers of natural medicine and therapies are not required by statute to be registered under the Health Practitioners Competence Assurance Act 2003, unlike mainstream providers of health services, such as doctors, dentists and physiotherapists. However, 42 different groups of practitioners involved in natural health care in New Zealand are represented by the New Zealand Charter of Health Practitioners Inc; members include practitioners of chiropractic, osteopathy, herbal medicine, meditation, acupuncture, homeopathy, Ayurvedic medicine, hypnotherapy, traditional Chinese medicine and Māori medicine.

The Charter was formed "to uphold the welfare and health concerns of the health consumer" by accrediting practitioners whose qualifications and practice meet an agreed professional standard. The Charter acts as a registration body that registers individual practitioners, approves Colleges (that teach providers) and accredits a variety of courses. Providers who are registered with the Charter are required to maintain their standards of practice, and need to gain a specified number of credits annually through participating in continuing education programmes to retain their registration. Chartered practitioner members in New Zealand are bound by a Common Code of Ethics and are subject to executive by-laws which deal with personal and professional conduct.

Selection of a natural health practitioner
Not all courses offered by an accredited College may be of adequate standard to gain approval, and not all providers offering natural therapies have passed appropriate training courses. Information about which providers are registered and which courses are accredited can be found in the New Zealand Charter of Health Practitioners Practitioner Directory. This publication is available in libraries and Citizens' Advice Bureaux nationwide. Otherwise, information can be obtained directly by telephoning the Charter at (09) 414 5501, or by visiting the website www.healthcharter.org.nz.

Practitioners who are not registered, or who have not completed an accredited course, are still required to provide services in accordance with their responsibilities as set out in the Code of Health and Disability Services Consumers' Rights.

Conclusion
Providers who meet their obligations under the Code, and consumers who make informed choices, will help create a safe environment in which alternative health procedures can be delivered.

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Test results: is no news good news?

Several complaints to the Commissioner's office have focused on distressing outcomes for consumers that have been caused by, or have involved, a breakdown in the process used by general practitioners for notifying patients about the results of their tests (99HDC11494, 00HDC02718, 00HDC07636, 02HDC18949). Doctors should provide patients who have had tests taken with any information they need arising from the tests, in a timely manner, so that further investigation or treatment can be carried out promptly.

Right 6(1) of the Code of Health and Disability Services Consumers' Rights sets out the right of consumers to be informed about the results of tests and procedures. Many GP practices take the approach that they will notify patients only when the results raise concerns. This is reasonable practice, given the significant resource implications of notifying all test results for all patients. However, in terms of the GP's responsibility under the Code, this practice is acceptable only so long as the patient is told, and agrees, that only abnormal results will be notified.

Therefore, if you are having tests done, you need to be clear about whether you will be notified of all results, or only abnormal results. You also need to be told how the information will be communicated to you. If you are not easily reached by telephone during working hours, you should advise the doctor how you wish to receive the information. For example, it may not be appropriate for information to be left as a voicemail message that may be accessed by others, or given to a third party.

It is also helpful to know when you may expect to receive notification. Some patients prefer to have some certainty around test results, and once the time for reporting has passed, rather than resting assured that 'no news is good news', they may worry that the medical practice has forgotten to follow up. Although doctors are required to have formal processes in place to track receipt of results from a testing facility, and follow up overdue results, errors can and do occur. If you are concerned about your test results, you should not hesitate to call the practice to confirm that your results have been received, and that they are normal.

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Test results: is no news good news?

(plain language version)

We at the Office of the Health and Disability Commissioner have come up with these ideas about how you can work with your doctor to find out about the results of your medical tests. We have received several complaints about upsetting events to do with test results.

If you have had medical tests, doctors should give you any information about the test results as quickly as possible. This is so that further investigation or treatment can be carried out as soon as possible.

Right 6(1) of the Code of Health and Disability Services Consumers' Rights sets out the right of consumers to be told about the results of tests and procedures. Many family doctors will tell you only when the results raise concerns. This makes sense because of the time it takes to tell everyone about their results.

However, you must have first agreed with your family doctor that he or she will tell you only about results that are of concern.

You also need to agree with the doctor how the results will be told to you. Doctors usually phone you with your results. But you may not be able to receive a telephone call during working hours or you may find it hard, even impossible, to use the telephone at all. If you can't take a phone call from the doctor, you should tell the doctor who your test results should be given to so they can be told to you in a private way.

It is also helpful to know when the results will come through. Although doctors must have processes written down to track receipt of results from a testing facility, and follow up overdue results, errors can and do occur. If you are concerned about your test results, you should call your doctor to confirm that your results have been received, and that they are normal.

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Tips for talking with your doctor

When things go wrong, it's almost always about failed communication. The Office receives about 1100 complaints a year, most of them ultimately related to a communication problem of some sort. "It can be the way people were talked to, whether they were given enough information; whether they were given a chance to really participate in the decision-making" says Rae Lamb, Deputy Commissioner Complaints Resolution.

Under the Code of Health and Disability Services Consumers' Rights, consumers have the right to effective communication in a form, language, and manner that enables them to understand the information provided. This includes the right to an environment that enables both consumer and provider to communicate openly, honestly and effectively.

Communication is about reaching a shared understanding of the issues under discussion - about talking and about listening, and recognising the messages that are conveyed by means other than words. Both parties need to feel comfortable in the environment for effective communication to occur. Exchange of information is an intrinsic part of effective communication and underlies the diagnosis and treatment processes: research indicates that the patient provides around 80% of the information their doctor needs to make a correct diagnosis; (other forms of information, such as physical examination, tests and medical records, provide just 20%).

Patient experiences
Even when patients know their doctor well and have a good relationship with him or her, there is potential for many issues to impact on the communication process during a consultation, creating barriers to effective exchange of information.

When visiting the doctor, patients report a variety of feelings including being nervous, embarrassed, afraid, vulnerable, powerless, resentful and frustrated. Under these conditions, patients may forget to provide all the information regarding the problem. Sometimes the patient avoids reporting the real difficulty altogether. Some patients may think they are wasting the doctor's time, or perceive that the doctor seems too busy to have enough time to attend conscientiously to the patient and the presenting problem. Even if a patient feels quite relaxed about the visit to the doctor, it is still possible that he or she may be selective about what information to provide, filtering out what may seem to be irrelevant. For example, some patients may not recognise that a medicine, supplement or natural remedy they buy from a supermarket or health food shop could contain components that cause changes in the body similar to those brought about by prescription medicines, and that information about such products should be provided to the doctor.

In addition to giving information there may be difficulties in receiving information. Research shows that some patients pick up less than 50% of the information given to them by doctors, and are not able to pay attention to everything they are being told. Frequently, patients are still absorbing information from the first sentence when the doctor is well into his or her second point. It is particularly difficult for patients to concentrate when they have just received bad news, or are in pain or experiencing a health crisis. The situation is compounded if the doctor uses medical terminology that the patient does not understand.

Maximising information exchange
There are practical steps patients can take to facilitate the exchange of information between themselves and their doctor.

In giving information, patients can:

• be prepared. Prior to visiting the doctor, patients can:

• take a friend or someone they trust to support them. This person may:

• give the doctor as much information about their health as possible, even if they think it is unconnected.

In receiving information, patients can:

• if in doubt - ask questions, especially if the doctor is using medical language
• ask the doctor to repeat or explain information that they do not clearly understand, or repeat information back to the doctor for confirmation
• take notes, or ask a friend to take notes
• share any internet information with the doctor. In this way the patient and the doctor can together discuss the various options.

Patients have the right to effective communication, and good communication is necessary for achieving good quality health care. Patients can take an active role in talking with their doctor, maximising the exchange of information, facilitating the communication process and contributing to better health outcomes.

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Tips for talking with your doctor

(plain language version)

When things go wrong, it's almost always about not talking and listening to each other. The Office of the Health and Disability Commissioner receives about 1100 complaints a year, most of them about not talking and listening with care. It can be the way people were talked to, whether they were given enough information; whether they were given a chance to really take part in making decisions.

The Code of Health and Disability Services Consumers' Rights spells out your rights. Among other rights:

• You have the right to support and care that suits you.
• You have the right to be told things in a way you understand.
• You have the right to be told about your health or disability.
• You have the right to support.

You and your service provider need to understand the issues being talked about, hearing all the messages that are being shared. You and your service provider need to feel comfortable so you can talk with each other well.

Research shows you give about 80% of the information your doctor needs to work out what is wrong with you. Other forms of information, such as physical examination, tests and medical records, give your doctor only 20% of the information.

What some people say about visits to the doctor

Even when you know your doctor well and like and trust them, things can happen that stop you from giving the information you need to pass on to your doctor.

When visiting the doctor, some people say they had a variety of feelings including being nervous, embarrassed and afraid. So you may forget to give all the information about your health problem. Sometimes some people may not even tell the doctor what is really wrong. Some may think they are wasting the doctor's time, or that the doctor seems too busy to have enough time to think carefully about the person and the problem being talked about.

Even if you feel quite relaxed about the visit to the doctor, you may leave out information that may not seem important. For example, some may not know that a medicine, or natural remedy they buy from a supermarket or health food shop could affect their health and that information about such products should be told to the doctor.

As well as giving information, it may be hard to receive information. Research shows that some people pick up less than 50% of the information given to them by doctors. They are not able to remember everything they are being told. It is really hard for people to think clearly when they have just received bad news, or are in pain or having a health crisis. It's even harder if the doctor uses medical terms that you don't understand.

Getting and giving as much information as possible

There are ways you can make it much easier to swap information between yourself and your doctor.

In giving information, you can:

• be prepared. Before you go to the doctor you can:

- make a list of all the health concerns that you wish to discuss with the doctor, with the most serious or important at the top

- make a list of all the medicines (including non-prescription products) that you are currently taking, or have recently stopped taking (and when)

- make a list of anything you have already done about your health problem, such as talking with other health professionals, for example a physiotherapist, or asking for advice from a pharmacist.

• Take a friend or someone you trust to support you. This person may:

- ask questions on your behalf

- remind you about information to give

- give you moral and emotional support

- advocate for you and make specific requests.

• Give the doctor as much information about your health as possible, even if you think it is not related to your problem.
• In receiving information, you can:

- if in doubt, ask questions, especially if the doctor is using words you haven't heard before

- ask the doctor to repeat or explain information that you do not clearly understand, or

- repeat information back to the doctor to be sure you have understood what he or she said

- take notes, or ask a friend to take notes

- share any internet information with the doctor. In this way you and your doctor can together discuss the various options.

You have the right to be told by your service provider about your situation and the right to discuss things until you clearly understand. A good understanding is necessary for getting good health care.

You can take an active role in talking with your doctor, making sure there is the best possible exchange of information and taking part in making better health outcomes for yourself.

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Waiting to be seen in accident and medical clinics

When injury or infection strikes outside the hours of normal general practice consultations, or holidaymakers and visitors find themselves in need of medical services, people are likely to seek help at the local accident and medical clinic. If the clinic is busy, some may spend several hours waiting for attention and - what seems worse - waiting while others who arrived after them are seen ahead of them. This may prompt the question: don't these people have a system?

Accident and medical clinics, and many general practices, have a system for dealing with patients in need of medical attention who arrive without an appointment. The system should ensure that those most urgently in need of care are prioritised for attention, and that decisions taken regarding the urgency of care - or even whether care is provided at all - are made by staff trained to make appropriate and safe decisions.

Need for prioritising
Sorting out how quickly a patient should be seen when there is a waiting time, and by whom (doctor, nurse, or referred to a hospital emergency department), is a complex matter. A priority process has to take into account the patient's need for treatment relative to others, as well as the resources available to provide that treatment. When there is no waiting time to see a doctor, the process is not needed, but when a clinic is very busy, staff have a responsibility to ensure that patients with most urgent need are seen ahead of those who can safely wait. How can appropriate prioritising be achieved?

Not all clinics have a formal system in place for prioritising urgent cases, and in fact many may not need one (see comment by HDC's independent advisor Dr Steven Searle in case 03HDC16186). Having a formal process where all patients receive preliminary assessment could actually compromise patient care rather than improve it, if the time taken for a nurse to perform the assessments results in increased overall delay for all patients.

Recognising urgent conditions
In most clinics, patients first register with the receptionist, who may record details about the reason for the consultation. The information provided by a patient to the receptionist can be very helpful in assisting the receptionist to weigh up the relative urgency of a patient's condition. If the patient has symptoms that may indicate the need for urgent treatment - such as shortness of breath or chest pain - or is very unwell, the receptionist can alert clinical staff. Training for all members of the practice team to enable them to recognise and respond appropriately to urgent medical conditions is identified as an essential standard for general practice, and in practices accredited under the College of General Practitioners quality improvement programme (Cornerstone), clinic staff, including receptionists, will have received this training (Aiming for Excellence - An Assessment Tool for General Practice 2002).

Return visits
It is well recognised that some conditions are difficult to diagnose in the early stages. For example, meningitis can resemble a viral flu-like illness (03HDC00575, 03HDC06973, 03HDC16186), while abdominal pain, vomiting and/or diarrhoea can lead to complications such as dehydration, or develop into appendicitis or perforated bowel (02HDC11786). Clinicians, who may be aware of a potential diagnosis but, at the time of the visit do not have the clinical evidence necessary to support it, will often advise patients to seek further attention if their condition deteriorates or does not improve. Patients returning for further assessment should advise the receptionist of this and outline the facts of the previous visit.

What to do
Whether or not a clinic has a process in place for sorting out who to see first when there is a wait for treatment, patients can enquire how consultations are prioritised when they register with the receptionist. If a patient believes the problem is urgent, or is very unwell, or is making a return visit because an ongoing condition is not improving, this should be brought to the receptionist's attention.