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Late patient demands to be seen

Dr Melanie Wynne-Jones discusses

Dr Melanie Wynne-Jones discusses

Case history

Miss Smith is your last patient of the evening, but turns up 20 minutes late just as you are about to leave. The receptionist tells her she will need to rebook. Miss Smith gets very upset, saying her problem is now urgent as she had to wait so long to get an appointment after work and it wasn't her fault the traffic is bad. She says she will go home and request a visit if you won't see her.

Which patients do GPs have to see and where?

The GMS2 contract specifies that GPs must see 'patients who are ill or believe themselves to be ill'. This includes patients inside the practice area who are registered with the practice, together with anyone temporarily living in or passing through the practice area and in need of urgent medical care. It applies to 'in-hours' – from 8am to 6.30pm, Monday to Friday. Outside these times, if the practice has opted out of out-of-hours care, the responsibility passes to the PCT-commissioned out-of-hours service.

However the GMC says that in an emergency, wherever it may arise, you must offer anyone at risk the help you could reasonably be expected to provide.

Where patients are seen is determined by the UK criteria which state that a visit is only necessary 'when, in light of the patient's medical condition, the doctor considers that such services are needed and would most appropriately be delivered by means of a home visit'. However most GPs, when faced with an inappropriate demand for a home visit, will go first and argue later, as a safeguard against mistakes and/or complaints.

Patients who threaten to go home and request a visit are either severely ill or stressed or simply manipulative.

Must you see Miss Smith?

If the appointment had been a bus she would have missed it! However, although the practice has fulfilled its obligations by giving her an appointment, and neither she nor the practice was responsible for the late arrival, her claim that her condition is now urgent makes it the practice's problem.

Practices vary in their response to this sort of request (and most GPs vary too, depending on how busy they are, whether the patient is a repeat offender, or whether there are extenuating circumstances). You could see her yourself, refer her to the duty doctor who is covering until 6.30pm, or advise her to rebook.

If it were after 6.30pm, it could be argued that the responsibility would pass to the out-of-hours service (although many GPs would still see her).

The arguments in favour of seeing her include:

  • Compassion
  • Contractual obligations
  • Preserving practice–patient and practice–out-of-hours relationships, and the practice's reputation
  • Avoiding a complaint (which may be time-consuming, even if unjustified)

The arguments against include:

  • Rewarding appointment abuse
  • You may be too tired or have another commitment
  • The duty doctor may be too busy (or simply unimpressed)

If her appointment had been earlier in the surgery, seeing her when she arrived would have meant all the subsequent patients would have faced undeserved delays. Some GPs would see her but insist that she waits until the others have been seen.

How can practices avoid DNAs?

Patients who 'did not attend' their appointments are a major problem, and in some practices waste more than 10 per cent of appointments. This reduces appointment availability for other patients, and puts pressure on receptionists and doctors, although many GPs are grateful for catch-up time to make phone calls or do paperwork.

Claims that DNAs cost the NHS more than £160m a year are spurious; GPs are independent contractors, and they, not the NHS, pick up the bill. Some practices deliberately over-provide; this can mean appointments going unfilled, tying down partners or paying for locum time that turns out to be unnecessary. The alternative is a long wait for routine appointments (which may in turn trigger more DNAs), demands by patients to be seen as extras, and pressure to achieve access targets.

Close monitoring of demand, a flexible approach to appointments, posters publicising the number of DNAs and reminding patients to cancel appointments they don't need can all help. Making it easy for patients to get through on the phone means that they are more likely to make the effort to cancel and even last-minute cancellations can often be filled. But missed appointments are increasing despite same-day slots being available.

How do practices manage repeat offenders?

A patient's failure to attend should always be noted on their record together with any reason or apology given. This provides medicolegal protection in case a patient later complains they could not be seen, and provides evidence if action is to be taken.

Removing patients from the list on the strength of one DNA is usually frowned upon, but many practices operate a 'three strikes and you're out' policy, sending a warning letter after the first or second time.

Most practices will be flexible about extenuating circumstances such as the patient with memory problems, carers who need cover, and events beyond patients' control (often traffic jams or public transport) but unfortunately, some patients (and families) do abuse the system. Fining patients who DNA has so far been considered politically and practically unacceptable.

Melanie Wynne-Jones is a GP in Marple, Cheshire

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