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Should we ever blame patients for wasting GP time?

Dr Karim Adab argues excusing patients makes it harder for GPs to provide good care while Dr Jonny Tomlinson says GPs should offer reassurance, not blame

YES

While GPs often feel uncomfortable placing blame on patients, we shouldn’t ignore the fact that, as adults sharing a finite resource, wants and needs must be moderated accordingly. Primary care can sometimes feel so overloaded with the former that it cannot respond to the latter.
In March, the support organisation Resilient GP documented almost 200 examples of what it deemed an ‘inappropriate use of GPs’ time and skills’. These included one patient requesting sick notes as an alibi for infidelity and another booking an appointment to complain that a sore throat had resolved on its own.

This was finally an acknowledgement that the public has a role in protecting the NHS. But proving that we GPs are sometimes our own worst enemies, it was met not just with a collective sigh of relief, but also by protracted hand-wringing from colleagues.

By contrast, patients generally responded sympathetically and were supportive towards our profession.

Of course, some groups of patients cannot be expected to recognise fully this collective responsibility for using GP appointments appropriately, for example those with mental illness or learning difficulties, or the frail and elderly. They are the ones who most need our help, the ones to whom we should make ourselves most accessible. Conversely, they also suffer most from the fallout of inappropriate demand. By excusing regular offenders we not only hand over problems to our colleagues - just as we do by inappropriate prescribing - but also penalise patients in real need.

While I’ll acknowledge GPs sometimes aren’t very good at ensuring our patients understand how we work, it’s clearly time to take action when in- and out-of-hours services are swamped, triage lists full of absurd, non-medical requests, and it is not unheard of for one person to miss two appointments in a single day.

While patient education needs to start with us, the responsibility cannot solely rest with a profession that is fighting to keep its head above water.

Whatever the next Government looks like, it needs to engage the public in an adult conversation about what the NHS can and cannot provide, and begin to fill some of the depressingly large gaps in the nation’s health education. We need to see more projects like ‘Not Always A&E’ to bring about lasting change in attitudes.

Nye Bevan famously spoke of the NHS as a communal responsibility, and that message now desperately needs revisiting.

Dr Karim Adab is a GP in Manchester


NO

The right to compassionate, empowering care is unconditional and this philosophy is what makes the NHS so precious.

As GPs, we must make a distinction between blaming someone and holding them responsible. Blame implies a finality, and is a bit like saying: ‘You’ve bought this on yourself so you’re on your own now’. As doctors, we are bound to work with patients who may be blameworthy, but they may also be vulnerable. It is not good enough for us to cast blame when we could be helping them take responsibility for their actions and change their behaviour for the better.

Encouraging patients to understand the consequences of their actions and to modify their behaviour is hard work - but it’s a vital part of a GP’s role.
The literature examining parents’ experiences of consulting with sick children shows parents are acutely sensitive to accusations of timewasting and hate being made to feel stupid for consulting either when their child was not sick enough to be worthy of a doctor’s attention or so sick that they should have consulted sooner.² ³ What parents want from doctors is not just reassurance, but confidence.

The studies show it is of little use to parents to be told their child is OK by the GP - what they actually want is the confidence to know what to do if their child is sick in the future. This confidence is empowering and it helps parents take responsibility for using our services appropriately. If we humiliate parents by questioning their judgment, they will leave anxious and upset and seek help elsewhere next time in the hope their fears won’t be belittled.

What’s more, blaming patients for what we deem to be an inappropriate use of our services is not only unhelpful to them, it’s unhelpful to us. Blaming others is a symptom and cause of our own unhappiness; when we are overwhelmed we tend to blame our patients for demanding too much, but doing so leaves both parties feeling miserable. Refusing to blame patients and accepting that stress is coming from elsewhere is actually a way of helping ourselves.

As GPs, we are in a position of power, and with this power comes the responsibility to protect the powerless. We shouldn’t talk disparagingly about ‘the entitled masses’ or berate them for having ‘rights without responsibilities’ without remembering this.

Dr Jonny Tomlinson is a GP in Hackney, east London

References

2 Neill S, Cowley S, Williams C. The role of felt or enacted criticism in understanding parents’ help seeking in acute childhood illness at home: a grounded theory study. International Journal of Nursing Studies 2013;50:757-67

3 Kai J. Parents’ difficulties and information needs in coping with acute illness in preschool children: a qualitative study. BMJ 1996;313:987-90

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Readers' comments (17)

  • WTF? the cheating husband certainly was not powerless, and should know better, and would be the source of the stress (rather than trying to accept it comes from elsewhere). Essentially, Dr Tomlinson, you can't generalise that you can never blame the patient, hence, its not wrong to be able to, in some cases.

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  • I think its rare to blame the patient who is eg worried about a cold or something else that to us seems a waste of our time but yeah the alibi thing and many of the other things on the resiliant GP list are ridiculous and most people should know better and those that dont should be advised gently that thats not what doctors do.

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  • All the blamed patients are behaving rationally with a benefits system that rewards illness and a primary care system where the marginal cost to the consumer is £0.
    Don't blame the patients, but don't be surprised that as GPs who have to beg government for our money, we are treated as beggars.
    The only answer is for direct pay GP services to be able to access the NHS.

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  • It is not difficult to figure out which of the above two GPs is most likely to suffer from burnout. Inappropriate demand is the cancer that is destroying NHS primary care.

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  • There are two sides to every story. Whenever I'm faced with a "WTF are you even in my consulting room?" scenario I'll spend the remaining minutes trying to explain to the parent/patient how to recognise signs of serious illness... at least for the first couple of encounters. After that it might get a little less empathetic 😏

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  • Yes

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  • Just remember, the patients' health is our concern but THEIR responsibility.

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  • Anonymous | GP Partner | 01 May 2015 8:16pm

    You put it perfectly. These patients consulting for non-medical reasons are often have perfectly reasonable and rational reasons for seeing us. E.g:
    1. That's not my domain, see your GP
    2. Need ESA - see GP for sick note
    3. Cold in your house? Government says see your GP
    4. Midwife won't refer to services she can refer to? See your GP
    5. Physio said I need an MRI - see your GP
    6. If you have questions about 'insert any issue you can think of' please see your GP
    7. Sorry we cant give you emergency housing, see your GP
    8. Sorry you'll have to pay for your carers - see your GP
    9. I need a sick note for my 10 weeks in hospital - here's one for a week then see your GP
    Etc etc.

    Everybody medical and non-medical is telling people to see their GP with ALL of life's ills, not just the medical problems. Is it a surprise that people come to see us then expecting us to be able to fix their 'shit life syndrome'? After all the government told them we can.

    Part of the responsibility lies with the patients, but the majority with the rest of the medical profession and the government/other services signposting everybody with any ailment to their GP. We are even our own enemies in this...we all know the colleagues who will give sick notes for every little thing and give in to completely inappropriate requests just to have an easier time, which of course spills over onto the rest of us.

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  • The problem is that seeking medical help for anything is the current zeitgeist. It is the same in countries where patients pay directly.

    The issue is why should GPs have to increase their consultation rate for the same income.

    Other industries can improve output through mechanisation. Unfortunately patients do not want automated on-line healthcare delivery, without any contact with a Doctor.

    Of course much of the job of a GP is reassurance, but patients want that in person from a GP.

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  • Well the government are patients too, so are GPs, therefore YES, we can blame patients!
    Dr Tomlinson just thinks everyone is naive and in need of educating, have fun educating my heartsinks!

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