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Will you register 'private' patient?

Case history

Your partner has inherited George, a charming, elderly patient who was looked after by your charismatic, now deceased senior partner 'privately' and paid a small fee for six-monthly visits. George lives some way from your practice boundary, lives alone, and was recently admitted as an emergency for COPD. He will need regular attention from the district nurses and support from other team members. He is

keen to remain in your practice, which he has known for several decades.

Your partner, who is clearly fond of him, asks if the practice will take him on as an NHS patient so that he can use the primary care team services.

What is your reaction?

Dr Peter Harvey

'We can't continue visiting him and the co-op definitely won't'

Our practice doesn't run personal lists, and agreeing to something like this is out of the question. Besides, it is unlikely George could have become that attached to the practice over the past few decades ­ staff have come and gone and we have moved premises more than once.

We, as a practice, do not condone any 'private' treatment of patients registered with us, not least because it is a breach of terms of service. He clearly has enjoyed the personal attention given to him by the late senior partner but he is due for a reality check.

George cannot expect a first-rate primary care service because he is so far from the practice boundary and it is untenable to suggest that a closer practice would be less capable. We are happy to visit patients whose clinical condition means they cannot travel to the surgery. But we would be unable to travel to him. Out-of-hours his area is covered by a different service and we could not expect our co-op doctors to go out of their way ­ this might jeopardise the care of other patients.

The unsentimental but responsible solution is to arrange for George to

re-register with a practice that covers his home, or to move to a suitable residential establishment in our area. I would refer his case to social services if the latter was possible. As for changing his GP, one of us would probably agree to call on him once to explain why we could not continue the arrangement, and advise him to re-register; the local PCT would be responsible for allocating him to a practice if he was unable to co-operate.

We would expect exactly the same procedure should this happen to a hitherto unregistered patient in our patch.

Peter Harvey completed the VTS in 1991 ­ he is a part-time GP in Norwich and is also an LMC secretary

Dr Sarah Humphery

'We may be able to keep him on, but he can't have private care'

Ideally, all the primary care team members who are likely to be involved in George's care should be consulted. He has a chronic condition, which will require ever-increasing amounts of input from health professionals. He is out of our area and this may mean involving different health visitors, district nurses or other staff from those who would normally see our patients. This may lead to funding issues if George happens to live in a different PCT. There is also the issue of communication between all the people involved.

He has been treated privately in the past, but our policy at the practice is not to see anyone for GMS privately. This will have to be explained to George. He may not be happy with this as he may have liked the status of having his own private GP. On the other hand if he can remain on the list he may be delighted to accept NHS care.

It is very important for George to be able to stay at the practice as he has been there a long time and staff know him. It can be very daunting for elderly patients who have a debilitating illness, like George, to have to join a new practice.

I would be willing to let him stay on the list but I would want to make sure that George knows the practice policy when it come to visits and phone calls. As a practice we will have to review our policy for patients out of area and be firmer in future.

If a patient wants to join the practice we have to be very strict about the area boundaries.

I am sure the next time I am swamped by a busy clinic, paperwork and phone calls, I will regret my decision to allow George to remain on the list, as he asks for yet another visit!

Sarah Humphery is a GP retainer in north London ­ she finished the VTS in 1997

Dr Chris Hall

'I don't think we should continue the late partner's arrangements'

My inclination is to be consistent ­ if there is an in-house policy on objective practice boundaries then, charming as George may be, it is unrealistic for him to be on the practice list.

Consensus among the partners and practice manager at our practice meeting and formulation of a policy on geographical boundaries and exclusion criteria would, of course, allow us to make the decision collectively. The late senior partner's private business arrangements should not necessarily imply a duty of care on his or her successors. The nature of, and demands on, general practice have radically changed since the era of our late colleague. If a partner really objected to the practice declining to take on George's care, they could, if they wished, look after him privately.

The problem is, if we were to accept George on to our list, a precedent would be set. It would then be difficult to remove from the list any subsequent patients found to be outside our geographical boundary. There is likely to be a neighbouring practice more suitably located to care for George.

It should be pointed out to him that our decision has got nothing to do with his state of health or age, but is about delivering a more appropriate, effective and, above all, safe level of care.

It would be prudent to explain to all concerned why the partners reached this conclusion. I should ready myself for the inevitable fallout ­ George has probably forged significant relationships with practice staff over the years.

The management of change is often painful but it could be eased if the practice helps the transfer of George's care to go smoothly. Ensuring effective communication with his new practice would be essential.

Chris Hall completed the VTS

in 1999 and is now a partner

in Belfast

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