Practice dilemma: A difficult patient wants to register with your practice

A patient with multiple health problems refuses to be seen by female or Asian doctors.

Practice dilemma (Photo: iStock)
Practice dilemma (Photo: iStock)

The dilemma

A patient with mental health problems and poorly controlled diabetes with multiple complications wants to register at the surgery. After warnings from a number of local practices, he has been removed as a patient because of his behaviour. He insists he does not want to be seen by any female or Asian doctors. However, he clearly needs access to good primary care services. How would you respond to his request?

A GP's response

Dr Louise Newson is a GP in the West Midlands

It is important to meet the patient to discuss this. You may prefer a colleague to be present too, for example, your practice manager.

The first question is the patient's medical history. It is important to obtain as much information as possible about his diagnosis, treatment and compliance. His mental health problems may be contributing to his poorly controlled diabetes. You should explore his understanding of his diabetes and its management to find out why it is not well controlled.

You also need to find out why he has been removed from other practice lists. Has he been verbally or physically abusive? Has he been unnecessarily demanding?

You will have to decide if it is acceptable to take on a patient who will not see female or Asian doctors. Patients often ask to see a GP of the same gender; although this may be feasible for routine appointments, you need to determine what would happen if only female GPs were available. Find out if he would see female practice nurses and explore why he is so specific about who he sees.

You may then decide to discuss his case in a partnership meeting.

A medico-legal opinion

Dr Zaid Al-Najjar is a medico-legal adviser at the Medical Protection Society

Although your immediate reaction may be that the patient's requests are offensive, he does need medical care for chronic conditions.

Under the GP contract, practices with an open list may only refuse a patient on reasonable grounds. This patient is not currently displaying challenging behaviour, so it would be difficult for a refusal to be considered reasonable.

If it is possible that his health problems might affect his behaviour, this should be taken into account. The GMC's Good Medical Practice states that doctors must treat patients and colleagues without discrimination.

If on further enquiry it is felt that his behaviour is unrelated to a medical condition, the practice should discuss his application with NHS England's local area team to see what support it may be able to provide.

It would be helpful to establish why the patient refuses to be seen by Asian or female doctors - is it a past difficulty or is this wholly discriminatory behaviour? Once this is established, the practice should decide whether the request is reasonable.

If you accept this patient, you should set him some ground rules. If he has a record of violent or threatening behaviour, the practice should take appropriate measures to safeguard staff.

The patient should be informed that the practice will do its best to cater for his preference, but that in emergencies or at short notice, it may be impossible to do so.

A patient's opinion

Danny Daniels is an expert patient

A pre-registration meeting should be arranged with the patient. If possible, a relative or friend should accompany him during this and any future visits to the practice.

At this meeting, you will have the opportunity to begin to understand the patient's needs and expectations, and gain insight into his problems.

The main aim of the meeting is to clarify what is acceptable in your practice. If you have a Patients' Charter in place, this could serve as the basis for your conversation.

This should be seen as the first step in building a relationship, which is, in itself, a two-way process.

It might be a good idea to meet practice partners and staff to discuss the case before meeting the patient and give feedback afterwards.

It is important to be consistent in all elements of the patient's dealings with staff. If an agreement is reached and registration sanctioned, it must be considered a good idea to evolve a plan that builds on this initial meeting, to enhance trust.

Gradually, the problems concerning his medical conditions can be broached and, hopefully, resolved.

There is a time element involved but if positive outcomes can be achieved, the time spent may be viewed as worthwhile. Reluctance to see female or Asian doctors is a separate matter - the patient's health is the top priority.

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