A patient is infuriated by CCG rules that mean his vasectomy must be done privately. He says you have an obligation to refer on the NHS. What do you say?
Dr Helen Cotton: Explain you agree with the referral in principle
The first step is to recover the consultation. Sticking to a rigid ‘no’ will inflame the situation. If you have no hesitation in agreeing to the referral on clinical grounds, explain this at the outset. Then discuss contraception fully with the patient, covering the delay in vasectomy effectiveness and short-term contraception needs, and exploring why permanent rather than long-acting reversible contraception is sought.
Defusing the anger will allow you to establish if vasectomy is the best option, and if so, whether an exceptional funding application may be possible, or if there is a suitable alternative.
Having had the clinical consultation, and ruled out other options, explain the CCG service restriction again. Give the patient a copy of the policy and the CCG complaints process, explaining that it is unlikely a vasectomy will be provided, but this is outside your control.
It is important to be aware of core GP skills and extended GP skills. Personally I have no expertise in health economics, commissioning, or medical politics, and am thus am unable to give a balanced view on rationing. However GPs have a responsibility to follow GMC leadership guidance.1 This requires doctors to be aware of resource limitations, providing the best, non-discriminatory service possible. Tying this with the GMC’s Good Medical Practice guidance, which stipulates respect for colleagues, the consultation is not the place to discuss personal views on rationing.2 If you wish to be involved in these decisions, it is worth engaging with the commissioning process.
Dr Helen Cotton is a GP in Yeovil, Somerset
Dr Zak Uddin: Seek to clarify the patient’s decision
This is an increasingly common scenario, with CCGs blocking access to procedures that were previously routinely provided. It is worth clarifying with the patient his understanding that vasectomy is usually non-reversible if he has a change of mind or circumstances. It may help to review if there are any long-acting reversible methods of contraception that might be acceptable to his partner. However, you need to explain this would require her to attend.
Offer empathy and apologise for his distress. This may help more than you would think. Explain that the decision not to offer the procedure on the NHS has been made at a higher level, and it is not you personally who is denying him the vasectomy. At the same time, do not opine on the appropriateness of the CCG’s ruling – the CCG is the governing body and by criticising it you risk coming across as unprofessional. Also, the patient might infer that you take responsibility, and suggest that the practice fund his surgery, which will create further conflict.
Some clinicians will still feel that a referral is appropriate. However, if you know that it will be rejected, you may make the situation worse by providing false hope – and will also generate unnecessary work. You may offer to write to the CCG on his behalf and explain his situation, while being careful not to promise a resolution. If the plea is rebuffed, you can suggest the patient personally seeks to raise his objections, for example by writing to his MP.
If you have established a good rapport and the patient definitely wishes to proceed with vasectomy, you may then discuss the costs of having treatment privately.
Dr Zak Uddin is a GP in Teesside
The medicolegal view: Be firm but sensitive and offer a second opinion
A patient demanding a service that is not available leaves the doctor in a difficult position – particularly when the decision to restrict access was not yours.
GMC guidance clearly expects doctors to put patients first,2 but observes that doctors must also be aware of limitations on resources and help ensure these are being used appropriately.
Further advice can be found in the GMC’s leadership and management guidance,1 which highlights that you must provide the best service within the resources available, complying with policy while keeping in mind your responsibilities to patients and the wider population. Decisions on access must be fair and not discriminatory, based on clinical need and the likely effectiveness of treatment. Discuss the patient’s circumstances. Inform them of the rules and consider any exemption criteria.
Being honest and sensitive, explaining the reasons for a service being unavailable will often defuse a patient’s anger. If they remain unhappy, you can offer a second opinion from another GP. This may help to allay any concern that you are mistaken.
Even so, some patients will remain angry. It is difficult not to take this personally, but if you are able to step back, it often becomes clear that the anger is not directed at you.
It may seem easier to accede to the patient’s request and remove yourself from the firing line. But this is unlikely to be useful in the long run, when the referral is bounced back. You could face criticism for offering something you knew could not be delivered.
If a patient makes a complaint, ask your defence organisation for advice.
Dr Gordon McDavid is a medicolegal adviser at Medical Protection
1 GMC. Good Medical Practice 2013 tinyurl.com/ydhfkcw2
2.GMC. Leadership and management for all doctors 2012 – paragraph 85 tinyurl.com/ybs96bpl