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Difficult patient who abuses services has re-registered

Your next patient, Mrs Battersby, has re-registered with the practice after a six-month defection and has insisted on an emergency appointment. The receptionist warns you to watch out, as the family caused major problems in the past. Mrs Battersby's opening gambit is a demand for some sleeping tablets, stronger painkillers and yet another referral for her bad back.

Dr Melanie Wynne-Jones advises.

Why do patients switch local practices?

In fact not many do, even when they are unhappy, although surveys repeatedly show most patients are satisfied with their GPs1. There is a subtle difference between changing from or to another surgery.

Patients arrive from another practice because they are dissatisfied with the attitudes or performance of the doctors, nurses or reception staff, or for geographical reasons (distance, hills, transport or shops). Sometimes they have been asked to leave, removed from the list, or allocated by the PCT.

However, patients may be attracted to a practice because of:

 · Personal reputations of the doctors and staff

 · Presence of a female doctor or nurse practitioner

 · Pleasant premises

 · Premises shared with a primary health care team

 · Geography

 · Ease of gaining appointments, visits, prescriptions, telephone access

 · Range of other services and specialist skills on offer

 · Attitude to sick children/creche facilities

 · Recommendation from friend/family member

 · Good public relations/advertising.

Should practices vet prospective patients?

This has logistical problems in that patients often leave registering until they need to consult a doctor, whereas vetting implies a delay while their case is considered, which may result in patient harm and lost registration/capitation fees2, 3.

Vetting also requires 'undesirables' to be defined. Recognising and sifting out patients who are rude, demanding, threatening or manipulative may not be easy on first acquaintance; there may be surprises when the notes arrive.

Vetting also raises ethical questions about equity of access to medical care, discrimination, false judgments and high-cost patients. It may spark accusations of 'cherry-picking'4.

Many practices successfully steer clear of these hazards but accept only patients who explicitly agree to practice policies, but some would argue this undermines patient choice.

What are 'allocated' patients? Which patients can be removed from the list?

All UK residents are entitled to be registered with a GP; if a GP does not want to accept a patient who is resident in the practice area and seeking treatment, this may be provided for a fee on an immediately necessary basis without further obligation2.

If all the local practices refuse to accept a particular individual or have closed lists, the PCT has both the power and a duty to allocate a patient for up three months. Many GPs were disappointed that the new contract did not address this5.

The practice can apply to have the patient removed immediately, but in the past a 'gentleman's agreement' usually operated whereby practices took their share of the burden before passing it on. This is changing as a result of GP shortages and increasingly unreasonable patient behaviour.

If a practice decides to remove a patient from the list it must notify the PCT in writing. Informing the patient is not compulsory but is considered good practice.

'Irretrievable breakdown of the doctor-patient relationship' is often cited4,6.

Patients who are violent can be removed immediately; practices willing to see them under strictly controlled conditions are eligible for extra funding7,8,9.

Should the father's sins be visited on the children?

This is difficult and should probably be dealt with on a case-by-case basis. It may be inconvenient and unfair to other law-abiding relatives if the family of a verbally or physically abusive patient is removed from the list en bloc4,6. But removing the perpetrator may still leave practice staff at risk if he can still accompany children to the surgery or during a home visit.

How should you respond to Mrs Battersby's demands?

Mrs Battersby may have left her previous practice at short notice, perhaps because she couldn't get what she wanted or had overstepped the mark.

You don't want to stereotype her, or deny her effective pain relief, but she may be economical with the truth, or at worst, addicted to, or selling on, the drugs she has requested.

This uncertain scenario is also not uncommon with temporary residents, and presents a difficult dilemma: do you risk antagonising a genuinely deserving patient or prescribe, knowing that you may be contravening safe practice or being taken for a ride?

The immediate solution is often to prescribe small quantities only, telling the patient you intend to telephone her previous GP and/or request her

notes urgently. This resolves the consultation and signals that you are willing to be helpful, but are not a soft touch.

The practice must discuss the Battersby family promptly to draw up a modus vivendi which if appropriate should be discussed with Mrs

Battersby, together with a warning that any

abuse of the practice this time round will result

in removal.

Key points

 · Patients who switch practices locally have good reasons for doing so

 · More patients are being allocated as a result of their difficult behaviour and/or GP shortages

 · GPs are increasingly expected to explain why they have removed patients from their lists

 · Vetting patients may be time-consuming and unethical

 · Violent patients may only be entitled to care under certain conditions, raising ethical questions about care of other family members

 · Some practices formally draw up ground rules with difficult patients

References

1 MORI. Patient satisfaction. 2002 www.mori.com/nhs/satisfaction.shtml

2 Ellis N, Chisholm J. Making sense of The Red Book (2nd edition). Oxford: Radcliffe Medical Press, 1993 (reprinted 1997)

www.redbook.i12.com/Index.htm

3 Revised statement of fees and allowances payable to GPs 2002/3. HMSO, 2002 www.doh.gov.uk/pricare/gpfees2002.pdf

4 Local medical regulation: working with good medical practice. GMC (2001) www.gmc-uk.org

5 GP contract, BMA, 2003 www.bma.org.uk/ap.nsf/Content/NewGMSContract

6 Removal of patients from GPs' lists guidance for college members.

Position statement. RCGP, 1997 www.rcgp.org.uk/rcgp/corporate/position/removal/index.asp#Editor%27s%

20Comments

7 Tackling violence towards GPs and their staff. DoH, October 2002

8 Primary Care ­ Preventing Violence and Abuse Against General Practitioners and Their Staff. We don't have to take this website and booklets (2001) www.nhs.uk/zerotolerance/intro.htm

9 Enhanced Service New GP Contract

www.nhs.uk/zerotolerance/general/index.htm

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