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At the heart of general practice since 1960

Right on mark over continuity

Three GPs share their approach to a practice problem

case history

You are asked to see a new patient at the end of a busy morning surgery. You are short of doctors due to sickness and holidays and you have a number of visits to make.

The new patient is an articulate young student with a lot of complaints and an awful lot to say for himself. He asks question after question, carefully writing down your answers on a clipboard that you can't see. You are very irritated but keep your cool.

After half an hour the consultation comes to an end and the patient reveals that he is an actor paid by a local health advocacy organisation which is compiling a report on local practices. The young man tells you that you have done well and have passed the test. He gives you a copy of his initial assessment and congratulates you. Your blood is boiling. What do you do next?

1. Dr Zoe Rogers

Zoe Rogers is a part-time salaried GP in Aylesbury, Bucks

‘I would like to know if this data collection technique is valid'

Just reading this has raised my blood pressure. If it really did happen to me, I would be shocked and angry.

With luck I would be calm enough to establish the fake patient's real name and address, and the name, address and phone number of the organisation he is working for. I would try to stay professional and tell myself he is simply an actor doing his job.

If he really lives in our practice area and has used his real name there is an issue of made-up symptoms being on his medical record, and of the doctor-patient relationship being damaged beyond repair. If he has used a false name and address it strikes me he has obtained services by deception.

In either case the next step would be to phone my defence organisation. I wonder whether discussing this with the PCT, complaining to the local patient advocacy organisation, and/or warning other local practices could constitute a breach of confidentiality and I would check before taking action.

I suspect an organisation like this is likely to publish the data and I would want to ascertain if there is anything to stop them. I would also like to know whether their data collection technique has been validated in any way. I feel collecting real opinions from real patients (as is frequently done as part of QOF) is likely to be much more relevant.

I would consider if there is any action the practice can take to stop this happening again. Perhaps there is something that could be tightened up in the registration procedure.

Looking on the bright side, at least I was patient and kept my cool!

2. Dr Keli Thorsteinsson

Keli Thorsteinsson is a GP in Shrewsbury

‘It is time to be very unfriendly – I don't care what he writes'

Stop acting cool. Tell the young confidence trickster in no uncertain terms that he has done nothing today to improve your health and if he ever wastes your time like this again he may need some health advocacy of his own.

How dare he and his stage-whisperers take up 30 minutes of your time like this! I might have forgiven him for three minutes, but even then I disagree with the principle of testing a professional's skill in this underhand way.

And I absolutely refuse to be tested by a group of people who have nothing to do with the regulation of doctors. ‘I have passed the test'! This young man really is asking for trouble. Should I throw caution to the wind and break off the constraints of the law and professional behaviour?

No. But it is time to be extremely unfriendly. I don't care what they write about me or the practice in their insignificant little leaflet because it won't affect a sensible person's opinion of the surgery. I would of course invoice this health advocacy organisation for 30 minutes of my time, plus aggravation pay. I may or may not append a letter with some helpful advice on how to conduct their business and where to do so in future.

A downside to putting thoughts on signed paper is that you can't deny them later and selected paragraphs may be taken out of context by the news-starved local media. But I really do feel angry about this.

3. Dr Trevor Rees

Trevor Rees is a partner in a training practice – he is also undergraduate tutor at the University of Birminghammedical school

‘I'd give his organisation both barrels, then call the LMC'

As far as I'm aware this type of subterfuge is not something I have to tolerate as part of my new contract, so I'd tell my spoof patient just what I thought of him. Then I'd get straight on the phone. My biggest problem would be deciding who to phone first.

Top of the list would probably be the person in charge of the local health advocacy organisation. He would get both barrels. I would point out that not only had the actor delayed me in my attempt to get through another day's paperwork and home visits, but he had quite likely denied a genuinely ill patient an appointment.

Next up would be a call to somebody at the PCT who either can deal with this outfit, or who even might have been involved in organising the test if the advocacy organisation had PCT backing. Letting them know how annoyed I was would help ease my stress. More importantly, it would let somebody in PCT Towers know that grassroots GPs won't tolerate this sort of time-wasting.

Finally I'd contact my LMC secretary to find out whether the LMC was aware that there were bogus patients on the loose in their patch. If they did know, I'd want to discover why I hadn't been warned. If they didn't, I would want to know if I had any form of redress.

what does this incident teach us?

Learning checklist

How should practices handle new patients?

• Should all new patients have a new patient interview? Before or after the registration is accepted? What should it include?

• Are GPs required to check bona fides/ NHS entitlement when patients register? Must GPs register all comers? What other options are there?

• QOF points are awarded for summarising new patients' notes. Would a summary have helped in this instance?

How does the practice manage resources?

• Is planning for holidays and sickness effective? How does it work and is it audited? Are there contingency plans?

• Are requests for visits and extras triaged? By whom?

• What are the pros and cons of advanced access?

• Is the QOF patient satisfaction survey important?

How should doctors deal with a patient who has a list of problems?

• What are the pros and cons of limiting the number of complaints dealt with, and/or allowing patients to book double appointments?

• Should extras be limited to a single urgent problem?

• Are these policies publicised and adhered to?

• Should this consultation have been curtailed in the interests of waiting patients? How?

• What strategies are effective for time management in the consultation?

• How does this square with patient centredness?

How should we deal with unusual patient behaviour?

• How do we feel about patients making their own notes? Are we entitled to see them? Are our records more valid than theirs?

• When and how should we deal with patients who appear to be wasting our time? What are reasonable grounds for a warning or removal from the list? What is the procedure?

• If this actor-patient is registered with the practice, can we complain about his behaviour to the PCT, LMC, or other GPs without breaching confidentiality?

• Handling this badly could affect the practice's reputation. Should the partnership agreement and employees' contracts specify what constitutes a critical incident, who should be informed, and how it should be handled?

• What support systems do doctors or other staff need?

Patient advocacy

• What systems does the NHS have for dealing with patients' concerns?

• What organisations (NHS, official or self-appointed) approach us on patients' behalf? What rights do they have to information or action?

• How should practices respond to inquiries from the press? Should they have a formal policy?

More information

• Entitlement to NHS Treatment (Jan 2005) (Department of Health) www.dh.gov.uk/assetRoot/04/08/08/26/04080826.pdf

• PALS – Patient Advice and Liaison Services (Department of Health) www.dh.gov.uk/PolicyAndGuidance/

OrganisationPolicy/PatientAndPublic

Involvement/PatientAdviceAndLiaisonServices/fs/en

• Advanced access (Department of Health) www.dh.gov.uk/PolicyAndGuidance/

OrganisationPolicy/PrimaryCare/

PrimaryCareTrusts/PrimaryCareTrusts

Article/fs/en?CONTENT_ID=4016138&chk=gvOn07

• Time Management in the Consultation (Well Close Square) www.gp-training. net/training/management/

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