James Slater gives his advice on how GPs can remove a patient from your list in a fair way, avoiding the Parliamentary and Health Services Ombudsman.
The recent Ombudsman's Annual Report included a (small) section on complaints about practices removing patients. It got (a lot of) publicity. So what have you got to do not to be in next year's report?
The Parliamentary and Health Services Ombudsman is the final port of call for people dissatisfied with services received from central government and the NHS. The Ombudsman has a proud track-record of standing up to authority on behalf of the citizen, for example, challenging successive governments over the Equitable Life debacle. Excellent stuff – except that you are authority and your dissatisfied patient is the citizen.
The Ombudsman has powers: the power of the annual report that gets media coverage; the power to ‘name and shame' and the power to impose financial sanctions.
However, the Ombudsman has restrictions too - it can never get involved until practice and local NHS procedures have been exhausted.
Can I adopt a cunning plan to handle significant complaints?
- Do everything you can to resolve the complaint locally
- Prepare your dossier contemporaneously
- Respect the Ombudsman
What can I do to resolve the complaint locally?
Acknowledge and address directly the emotions involved, including yours, but work through an objective process.
If possible, face-to-face contact or telephone conversation is always better than letters alone, and when you do write seek independent advice on your drafts.
Be clear in all your actions, discussions and correspondence that lodging a complaint and patient-removal are entirely separate processes.
Some patients express dissatisfaction but refuse to lodge a complaint for irrational reasons and practices will strive really hard to avoid formally recording a complaint, for equally irrational reasons, – but it is probably better to formalise these concernsat this stage and treat their dissatisfaction as a complaint.
Ask yourself these questions:
- Are you absolutely sure of the information in front of you? Have you checked? Are those facts documented and captured within your dossier?
- Are there issues relating to your practice performance?
- If you are considering patient-removal, have you held a ‘yellow-card' meeting? If not, why not? Two justifiable steps are always more defensible than one risky one.
Do I really need to record all communication at this point?
Yes, because you've made a significant decision. Now your decision requires a thorough record of the supporting evidence. Particularly, as you could be entering a quasi-legal process – at a later time - when you will not be able to rely on your memory. And the aggrieved patient will remember everything in increasingly vivid detail.
As a jaded member of an employment tribunal once said to me: ‘I am tired of besuited, professional people promising me something happened. If there is no contemporaneous documentary evidence, I now assume it did not'. So, get even and get documenting!
How can I prepare a decent and contemporaneous dossier?
Following the BMA guidance, write a letter that sets out your investigation and decision and the patient's right to appeal. In addition to this, compile a dossier of evidence that supports your decision.
The dossier should contain all the content that supports your letter and your decision. In particular, this must include reasonably-contemporaneous notes of incidents, meetings and telephone calls.
Review the dossier in your practice team for lessons learned - and record what you have changed. Make sure you retain this and refer to it – do not rely on your memory.
What will happen if I lose?
If you've run the full process and lost – give up. Apologise and establish what the Ombudsman would like you to do. Or don't – and prepare to be named in next year's Ombudsman's annual report. Do you have a good photo for the tabloids to use? Excellent …
Any other advice?
No practice can please every patient all of the time. Conversely, no patient (or family member) should have to put up with what they view as inadequate or inappropriate care.
Adopting the combination of an open-minded approach to dissatisfaction together with documentation of the dissatisfaction and attempts to manage it (including reasons for separation) can only be of benefit to all. And the Ombudsman will approve... I promise…(and yes, I am wearing a suit …)
James Slater is director of Redriffe and an associate with Intellego Healthcare.
