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GPs buried under trusts' workload dump

Take on

difficult

patient

and earn goodwill

says PCT

Three GPs share their approach to a practice problem

Case history

Out of the blue, you get a phone call from a senior member of staff from the PCT. He is very friendly and chatty and after asking after your family (he does not even know you have a family) he wonders if you would take a patient on to your list. It transpires that this patient has a pathological hatred of doctors and regularly files complaints with the GMC about almost every doctor he comes across. The PCT official says it is your turn to take this patient and hints there would be a lot of 'goodwill' shown towards your practice, if you accept.

Dr Trevor Rees

'Allocations are part of life but I resent the tone

of this'

Allocations are a part of life for GPs, so I wouldn't be too upset to have this patient allocated to me.

But I would be unhappy at the manner which has been adopted by this senior figure at the PCT.

I really don't have a huge amount of time for NHS bureaucracy and this episode would do nothing to change that view.

I would agree to have the patient, but I would like to get an idea about what the

previous problems have been. Forewarned is forearmed.

I don't have any real qualms about the clinical side of managing this particular patient as I keep good records, I'm reasonably competent, and I don't get involved in too many slanging matches with patients, but it's still important to know what one is dealing with. What, exactly, does 'a pathological hatred of doctors mean'?

Is the patient verbally or physically abusive, for example?

Then I would get down to the nitty-gritty of the ingratiating attitude of the PCT

official. I realise that in this day and age we sometimes have to adopt an 'I'll scratch your back if you scratch mine' relationship with PCTs, and I wouldn't mind this sort of

approach if it was from somebody who

genuinely knew me professionally or

socially.

But this guy makes me feel I'm almost being blackmailed into accepting the patient. I get goodwill if I do accept; but goodness knows what if I refuse.

I'd make it clear during the phone call that I did not appreciate the unprofessional methods of coercion.

I'd also make it clear that I would take the matter up with one of my GP colleagues on the PEC or the board of the PCT and make sure my displeasure was known about at the highest level.

I might also have a chat about it with my LMC secretary.

Trevor Rees finished VTS in 1983 – he is a partner in a

six-partner training practice and undergraduate tutor at the University of Birmingham Medical School

Dr Patricia Cahill

'The patient may be difficult because of ill-health'

This patient may have a medical

condition that necessitates him seeing doctors. Otherwise why would he bother

trying to register with one if he hates the medical profession? It seems unfair if a person who needs medical care is discriminated against because of his 'complaining' habit.

He might be behaving like this because of ill-health. It could also be that he doesn't feel listened to or taken seriously.

This would not be surprising if the doctors with whom he consults are hindered from giving him a fair hearing, because they know what he has done to their colleagues and fear what he might do to them. It is also possible that this man's complaints to the GMC in the past have been justified.

The PCT official's manner is very off-putting. I like to think that everyone in our practice works very hard. The concept of wanting or needing to win brownie points from the PCT would not be an added

inducement to me to want to take the

patient. It comes across as a bit offensive. However, this PCT official may just lack social skills and may be trying to be nice.

This could also be viewed as a warning about the patient. As this is done through a phone call it means the PCT staff member can be more frank than in a letter.

Having to answer a complaint to the GMC is extremely stressful; time-consuming, emotionally painful as well as potentially damaging to reputations, even when the complaint is totally unfounded. Once this man is registered, from what the PCT man is telling me, he is likely to make a complaint sooner or later. Technically if I am not doing anything wrong, I have nothing to worry about – but that is easier said than done.

If the patient is allocated to the practice there is little option but to take him unless he lives out of the practice area. We would have to get on with it and hope for the best.

Patricia Cahill is a salaried GP in Ipswich

Dr Steve Brown

'I would want to clarify what they mean by goodwill'

When somebody asks me to do a favour I automatically think 'what are they after in

return?'. This is particularly true in this case. I would like to find out more about these previous complaints, which doctors he has been registered with and for how long. It would be good to speak to the other doctors.

I have been allocated patients by the PCT

before and sometimes their behaviour changes with a different doctor and practice. However, this patient does not sound as if he will change.

I would talk to my partners, as obviously they will be affected by the patient (and also patients are now registered with a practice not an individual doctor), and a partnership decision would have to be taken. I would check with my defence union as to what

behaviour would necessitate the patient

being taken off the list.

I would want to clarify exactly what this 'goodwill' issue is. I would like to think that our practice does not have to earn goodwill and that the PCT treats all practices the same. It would be vital to get something clear from the PCT manager in writing as memories of phone conversations can vary.

If we accepted the patient the issues would have to be discussed at the practice primary care team meeting so that there was understanding and consistency from everybody. A contract could then be drawn up and agreed with the patient at the first meeting.

Steve Brown is

a partner and

GP tutor in Beaconsfield, Buckinghamshire

Learning checklist

Allocation of patients

• Patients having difficulty registering with a GP are entitled to be allocated

a GP by the PCT.

• Allocations are usually made on a

rota basis among local GPs but this depends on practice areas and practices with closed lists do not have to participate.

• A variety of difficult-to-doctor schemes have arisen. In some areas, they are exclusively for patients with a history of violent or threatening behaviour but in others being thrown off two doctors' lists within a 12-month period qualifies. In return for significant financial incentives, some practices have agreed to deal with these patients.

Personal requests from the PCT

• Personal approaches by the PCT may allow you to discuss the patient's previous problems. The PCT may also be able to offer some conciliation to the patient and support to the practice. Other possible benefits may, for example, be in allocating a patient with drug misuse problems to a practice with a well established shared-care scheme.

• Disadvantages lie in unfairness in terms of workload and personal risk. It is also difficult to see how the PCT can reward this 'goodwill'.

Strategies for managing potentially difficult allocations

• Being removed from a doctor's list can be devastating for a patient. It can result in labelling and mistrust for both parties. It is usually worth giving the newly allocated patient the benefit of the doubt.

• Get the old notes sent to you urgently, summarise them and talk to the previous GP.

• At the first appointment look for signs of mental illness and social problems and also discuss problems with previous GPs. Try to gain at least a verbal agreement about how to access and use services and what you expect from the patient in return.

• Record all contacts with the patient very carefully and act early if problems seem to be arising. Offer an appointment to discuss any issues and write to explain what has happened and what might happen if they continue to behave in this way.

Complaints

• Always try to deal with complaints in-house. Find out what happened, why, offer to meet the patient and listen to their point of view and apologise appropriately. Use complaints as a catalyst to improve services using the significant event system.

• Patients who have difficulty voicing their complaint or fitting in with the system may benefit from advocacy from patient advice and liaison services.

• Some patients will never be satisfied and exhaust the three tiers of the complaints system but continue to complain, or raise different aspects

of the same problem or become malicious towards those trying to sort out their problems. They can be dealt with at a PCT level and labelled 'vexatious complainers'.

Richard Stokell is a GP in Birkenhead, Merseyside

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